MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL

MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providersi

MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL

Training Module For Health Care Providers

Asma layout.indd 1 11/26/14 3:15 PM

iiMANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers

PAGE CHAPTER I

MANAGEMENT OF ASTHMA 1 Topic 1 Management of Asthma at Primary Care level

41 Topic 2 Update on Management of Asthma and Assessment Tool

47 Topic 3 Assessment and monitoring asthma and clinical action plan

51 Topic 4 Management of Childhood asthma according to Malaysia CPG

63 Topic 5 Inhaler technique and pharmacotherapy in asthma management.

87 Topic 6 Application of Peak Flow Meter (PFM) and Spirometry in management of asthma

97 Topic 7 How to interpret Spirometry result

CHAPTER II

QUALITY ININATIATIVE OF ASTHMA103 QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA”

CHAPTER III

ASTHMA DSA PROJECTS 111 1. Management of bronchial asthma in health clinic: outcome & remedial measures conducted

at Health Clinic Tampin since 2008

117 2. Improving QA asthma through a district specific approach - District Office Kuala Langat

123 3. Elevate the percentage of controlled bronchial asthma at Pendang District

133 4. Increase the implementation of Controlled Asthma among the asthmatic patient in Perlis

139 Appendix I

CONTENTS


MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providersiii

Dr Kamaliah binti Mohamad NohDeputy DirectorPrimary Care SectorFamily Health Development Division

Dato’ Dr Hj Abdul Razak MuttalifRespiratory Consultant Institute of Respiratory MedicineHospital Kuala Lumpur

Dr Norzila binti Mohamed ZainudinConsultantPaediatric Institute Hospital Kuala Lumpur

Dr Norhayati binti Mohd MarzukiSpecialistInstitute of Respiratory MedicineHospital Kuala Lumpur

Dr Fatanah binti IsmailPublic Health PhysicianPrimary Care SectorFamily Health Development Division

Dr Nazma binti SallehPublic Health PhysicianPrimary Care SectorFamily Health Development Division

Dr Noraini binti YusoofPublic Health PhysicianPrimary Care SectorFamily Health Development Division

Dr Iskandar Firzada bin Hj OsmanFamily Medicine Specialist Health Clinic Jaya Gading, Kuantan, Pahang

Dr Norsiah binti AliFamily Medicine Specialist Health Clinic Tampin, Negeri Sembilan

Dr Nor Azila binti Mohd IsaFamily Medicine Specialist Health Clinic Telok Datuk, Banting, Selangor

Dr Junaidah binti IshakPublic Health PhysicianPrimer Officer, Perlis

Pn Syuhadah binti AhadPharmacist Hospital Melaka

Ruzita Bt SaadNurseHealth Clinic Pendang,Kedah.

1. Dr Fatanah binti Ismail Public Health Physician Primary Care Sector Family Health Development Division

2. Dr Nazma binti Salleh Public Health Physician Primary Care Sector Family Health Development Division

3. Dr Natasya Nur binti Mohd Nasir Medical Officer Primary Care Sector Family Health Development Division

CONTRIBUTORS

EDITORS


ivMANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers

INTRODUCTION

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. Symptoms are triggered by viral infections (colds), exercise and allergen exposure, changes in weather, laughter, or irritants such as car exhaust fumes, smoke or strong smell trigger.

The narrowing of the airways and increase in mucus production due to these trigger factors, will reduces the flow of air in and out of the lungs, resulting in an asthma attack. It is estimated that there are 300 million asthmatics globally. National Health Morbidity Survey 2006 showed a prevalence of adult asthma was 4.5% and childhood asthma up till 18 years old was 7.14%. Intermittent asthma among adult was 7.2% and persistent asthma has 25.8% while 68.1 % experience acute exacerbations of bronchial asthma.

Level of asthma control among community is still low at 32.9% in a study done in Perak from 2007 till 2009. In a 2009 study done in Selangor, 93.8% of asthmatic patients did not perform the PEF test, 62.7% demonstrated a wrong inhaler technique and only 66.3 % patient knew the care plan for an acute asthma attack Therefore, there is an urgent need for the management and monitoring of asthmatic patient at the primary care level to be strengthened.

Patient’s knowledge to manage their asthma is highly dependent on patient education given to them by the healthcare provider. In the primary care clinic the patient is handled by the primary health care team including doctors, nurses, assistant medical officer, pharmacist and assistant pharmacist. In service training of the primary health care team to maintain competency in managing asthma need to be conducted regularly at the implementation level. With the development of this module the training for providers at primary care setting will be facilitated.

During the workshop and the course, all the physicians such as Respiratory Physicians, Family Medicine Specialist, Public Health Specialist, Pharmacist, and the paramedic shared their experiences and made initiatives in developing this module. Good practices, innovation and learning tools in implementation of asthma are shared in this module


MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers1



TOPIC 1


2MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers

TOPIC 1: MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL TRAINING MODULE FOR HEALTH CARE PROVIDERS

SLIDE 1

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Learning objective

• Definitionandpathophysiologyofasthmawillbediscussedinthischapter

• The paramedicwill be able to use clinical examination, investigation and assessment tools duringtriaging at the health clinic.


Outline1. Definition2. Pathophysiology3. Outcome4. Diagnosis5. Classification6. Management

DefinitionChronic lung heterogeneous disease characterised by recurrent/episodic/paroxysmal breathing problems & symptoms such as;

• Breathlessness• Wheezing• Chest tightness• Coughing



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Symptoms of asthma attack

Definition

Normal Lungs Asthma Lung



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Pathophysiology• Chronic inflammatory disorder of the airways. (Host)• Airways are hyperresponsive; become obstructed (bronchoconstriction, mucus

plugs, & increased inflammation) when exposed to various risk factors. (Host)• Common risk factors; allergens (house dust mites, animals with fur, cockroaches,

pollens, molds), occupational irritants, tobacco smoke, respiratory (viral) infections, exercise, strong emotional expressions, chemical irritants, & drugs (aspirin & beta blockers). (Environment)

Pathophysiology

Outcome• Acute respiratory failure.• Irreversible airflow limitation (airways remodelling).• Troublesome symptoms night & day.• Limitations of physical activities / activities of daily living.

Airway lumen Ciliatedepithelial cells

Blood vessel

Mucous glandBronchial

smooth muscle

ConstrictedBronchioles



SLIDE 8 Diagnosis

Several ways:• Clinical symptoms & medical history.• Lung function measurement.• Trial of treatment; marked clinical improvement during the treatment &

deterioration when treatment is stopped.

Clinical symptoms & medical history;• Recurrent cough / wheeze / difficult breathing / chest tightness particularly

at night or in the early morning or after exposure to risk factors or worsen at night (awaken the patient) & has eczema, hay fever, family history of asthma or atopic diseases.

• Patients colds “go to the chest” or take more than 10 days to clear up.

Clinical symptoms & medical history (<5 years);• Frequent episodes of wheezing – more than once a month.• Activity-induced cough or wheeze.• Cough particularly at night during periods without viral infections.• Symptoms that persist after age 3 years.• Symptoms occur or worsen in the presence of risk factors.• The child’s colds repeatedly “go to the chest” or take more than 10 days to

clear up.• Symptoms improved when asthma medication is given.

Physical examination in people with asthma;• Often normal• The most frequent finding is wheezing on auscultation, especially on forced

expiration.

Wheezing is also found in other conditions, for example;• Respiratory infections.• COPD.• Upper airway dysfunction.• Endobronchial obstruction.• Inhaled foreign body.

Wheezing may be absent during severe asthma exacerbations (‘silent chest’).

Lung function test / measurement;1. Provide an assessment of the severity, reversibility, & variability of the airflow

limitation (confirm diagnosis).2. Spirometry; ↑ FEV1 > 12% & > 200 ml after bronchodilator (reversibility).3. Peak Expiratory Flow (PEF);§ Compared to previous best measurements using his/her own peak flow meter.§ ↑ 60 L/min (> 20%) after bronchodilator (reversibility) or diurnal variation >

20% (2x daily, > 10%) (Variability).



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Diagnosis



SLIDE 11Diagnosis



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DiagnosisDiagnostic Challenges• Cough-variant asthma• Exercise-induced bronchoconstriction• Children 5 years & younger• Asthma in the elderly• Occupational asthma• Asthma-COPD Overlap Syndrome (ACOS)

Classification1. Classification of asthma severity by clinical features before treatment. 2. Assessment of levels of asthma control;

• Clinical symptoms & objective measurement;- GINA Guidelines

• Clinical symptoms & subjective perception;- Asthma Control Test (ACT)



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Classification of asthma severity by clinical features before treatment

SYMPTOMS

SeverePersistent

- Symptoms is daily- Frequent exacerbations- Frequent nocturnal asthma symptoms- Limitations of physical activity - FEV1 orPEF≤60%predicted- PEF or FEV1 Variability > 30 %

ModeratePersistent

- Symptoms daily- Exacerbations may affect activity and sleep- Nocturnal symptoms more than once a week- Daily use of inhaled short acting β2 - agonist - FEV1 or PEF 60% - 80% predicted- PEF or FEV1 Variability > 30%

Mild

Persistent

- Symptoms more than once a week but less than once a day- Exacerbations may affect activity and sleep - Nocturnal symptoms more than twice a month - FEV1 orPEF≥80%predicted- PEF or FEV1 Variability < 20 – 30%

Intermittent - Symptom less than once a week- Brief exacerbations Nocturnal symptoms not more than

twice a month FEV1 orPEF≥80%predicted- PEF or FEV1 Variability < 20 %

GINA Assessment of Asthma Control1. Asthma control – two domains

• Assess symptom control over the last 4 weeks.- Assess risk factors for poor outcomes, including low lung function.

2. Treatment issues• Check inhaler technique and adherence.• Ask about side-effects.• Does the patient have a written asthma action plan?• What are the patient’s attitudes and goals for their asthma?

3. Co-morbidities• Think of rhino sinusitis, GERD, obesity, obstructive sleep apnoea,

depression, anxiety.• These may contribute to symptoms and poor quality of life.



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GINA Assessment of Asthma Control and assessment of asthma control (adult and children) (appendix 1: Topic Management of Asthma at primary care level)

Management

Treatment book for asthmatic patient

Primary prevention of asthma1. The development and persistence of asthma are driven by gene -environment

interactions.2. Current recommendations are;

• Avoid exposure to tobacco smoke (ETS) in pregnancy and early life.• Encourage vaginal delivery.• Advise breast-feeding for its general health benefits.• Where possible, avoid use of paracetamol (acetaminophen) and broad-

spectrum antibiotics in the first year of life.



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Treating asthma to control symptoms and minimize riskGoals of asthma management1. The long-term goals of asthma management are;

• Symptom control: to achieve good control of symptoms and maintain normal activity levels.

• Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation and medication side-effects.

2. Achieving these goals requires a partnership between patient and their health care providers;• Ask the patient about their own goals regarding their asthma.• Good communication strategies are essential.• Consider the health care system, medication availability, cultural and

personal preferences and health literacy.

3. Establish a patient-doctor partnership.

4. Manage asthma in a continuous cycle;- Assess- Adjust treatment (pharmacological and non-pharmacological)- Review the response

5. Teach and reinforce essential skills;- Inhaler skills- Adherence- Guided self-management education;

- Written asthma action plan- Self-monitoring- Regular medical review (follow-up)

The control based asthma management cycle



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Choosing between controller options on population level decisions

Choosing between treatment options at a populatione.g. National formularies, health maintenance organisations, national guidelines

The ‘preferred treatment’ at each step is based on:qEfficacy qEffectivenessqSafetyqAvailability and cost at the population level

Based on group mean data for symptoms, exacerbations and lung function (from RCTs, pragmatic studies and observational data)

Choosing between controller options – individual patient decisions

Decisions for individual patientsUse shared decision – making with the patient / parent / carer to discuss the following:

1. Preferred treatment for symptoms control and for risk reduction 2. Patient characteristics (phenotype)

- Does the patient have any known predictors of risk or response(e.g. smoker, history of exacerbations, blood eosinophilia)

3. Patient preference- What are the patient’s goals and concerns for their asthma

4. Practical issues- Inhaler technique – can the patient use the device correctly after

training?- Adherence: how often is the patient likely to take medication?- Cost: can the patient afford the medication

Choosing between controller options – individual patient decisions• Inhaled medications are preferred because drugs delivered directly to the

airways, results in potent therapeutic effects with fewer systemic side effects.• Inhaled glucocorticosteroids – most effective controller.• Spacer makes inhalers easier to use & reduce systemic absorption & side effects

of inhaled glucocorticosteroids.



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Choosing between controller options –individual patient decisions

Initial controller treatment for adults, adolescents and children 6–11 years1. Start controller treatment early;

– For best outcomes, initiate controller treatment as early as possible after making the diagnosis of asthma.

2. Indications for regular low-dose ICS - any of;– Asthma symptoms more than twice a month.– Waking due to asthma more than once a month.– Any asthma symptoms plus any risk factors for exacerbations.

3. Consider starting at a higher step if;– Troublesome asthma symptoms on most days.– Waking from asthma once or more a week, especially if any risk factors for

exacerbations.

4. If initial asthma presentation is with an exacerbation;– Give a short course of oral steroids and start regular controller treatment

(e.g. high dose ICS or medium dose ICS/LABA, then step down).

Initial controller treatment1. Before starting initial controller treatment;

• Record evidence for diagnosis of asthma, if possible.• Record symptom control and risk factors, including lung function.• Consider factors affecting choice of treatment for this patient.• Ensure that the patient can use the inhaler correctly.• Schedule an appointment for a follow-up visit.

2. After starting initial controller treatment;• Review response after 2-3 months, or according to clinical urgency.• Adjust treatment (including non-pharmacological treatments).• Consider stepping down when asthma has been well-controlled for 3

months.



SLIDE 26 Stepwise approach to control asthma symptoms and reduce risk

*For children 6-11 years, theophyline is not recommended, and preferred Step 3 is medium dose ICS.

** for patients prescribed BDP / Formoterol or BUD / formateral maintannce and reliever therapy.



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Stepwise management – pharmacotherapy

Stepwise management – additional components



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Step 1 – as-needed inhaled short-acting beta2-agonist (SABA)

Step 1 – as-needed reliever inhaler1. Preferred option: as-needed inhaled short-acting beta2-agonist (SABA);

• SABAs are highly effective for relief of asthma symptoms.• However …. There is insufficient evidence about the safety of treating

asthma with SABA alone.• This option should be reserved for patients with infrequent symptoms

(less than twice a month) of short duration, and with no risk factors for exacerbations.

2. Other options• Consider adding regular low dose inhaled corticosteroid (ICS) for patients

at risk of exacerbations.

Short Acting Beta Adrenergic (SABA) inhaler

Inhaled Corticosteroids (ICS)



SLIDE 31 Step 2 – low-dose controller + as-needed inhaled SABA

1. Preferred option: regular low dose ICS with as-needed inhaled SABA;• Low dose ICS reduces symptoms and reduces risk of exacerbations and

asthma-related hospitalization and death.

2. Other options;• Leukotriene receptor antagonists (LTRA) with as-needed SABA;

- Less effective than low dose ICS.- May be used for some patients with both asthma and allergic rhinitis,

or if patient will not use ICS.



SLIDE 32 Step 3 – one or two controllers + as-needed inhaled reliever

1. Before considering step-up;• Check inhaler technique and adherence, confirm diagnosis.

2. Adults/adolescents: preferred options are either combination low dose ICS/LABA maintenance with as-needed SABA,OR combination low dose ICS/formoterol maintenance and reliever regimen*• Adding LABA reduces symptoms and exacerbations and increases FEV1,

while allowing lower dose of ICS.

3. Children 6-11 years: preferred option is medium dose ICS with as-needed SABA.

4. Other options;• Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less

effective than ICS/LABA).• Children 6-11 years – add LABA (similar effect as increasing ICS).



SLIDE 33 Step 4 – two or more controllers + as-needed inhaled reliever

1. Before considering step-up;• Check inhaler technique and adherence

2. Adults or adolescents: preferred option is combination medium dose ICS/LABA with as-needed SABA, OR combination low dose ICS/formoterol as maintenance and reliever regimen*• Children 6–11 years: preferred option is to refer for expert advice.• Other options (adults or adolescents);

- Trial of high dose combination ICS/LABA, but little extra benefit and increased risk of side-effects.

- Increase dosing frequency (for budesonide-containing inhalers).- Add-on LTRA or low dose theophylline.



SLIDE 34 Step 5 – higher level care and/or add-on treatment

1. Preferred option is referral for specialist investigation and consideration of add-on treatment;• If symptoms uncontrolled or exacerbations persist despite Step 4

treatment, check inhaler technique and adherence before referring.• Add-on omalizumab (anti-IgE) is suggested for patients with moderate or

severe allergic asthma that is uncontrolled on Step 4 treatment.

2. Other add-on treatment options at Step 5 include;• Sputum-guided treatment: this is available in specialized centres; reduces

exacerbations and/or corticosteroid dose.• Add-on low dose oral corticosteroids (≤7.5mg/day prednisolone

equivalent): this may benefit some patients, but has significant systemic side-effects. Assess and monitor for osteoporosis.



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Low, medium and high dose inhaled corticosteroids Adults and adolescents (≥12 years)

• Thisisnotatableofequivalence,butofestimatedclinicalcomparability.• MostoftheclinicalbenefitfromICSisseenatlowdoses.• Highdosesarearbitrary,butformostICSarethosethat,withprolongeduse,

are associated with increased risk of systemic side-effects.

Low, medium and high dose inhaled corticosteroids Children 6–11 years

• Thisisnotatableofequivalence,butofestimatedclinicalcomparability.• MostoftheclinicalbenefitfromICSisseenatlowdoses.• Highdosesarearbitrary,butformostICSarethosethat,withprolongeduse,

are associated with increased risk of systemic side-effects.



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Reviewing response and adjusting treatment1. How often should asthma be reviewed?

• 1-3 months after treatment started, then every 3-12 months.• During pregnancy, every 4-6 weeks.• After an exacerbation, within 1 week.

2. Stepping up asthma treatment;• Sustained step-up, for at least 2-3 months if asthma poorly controlled;

- Important: first check for common causes (symptoms not due to asthma, incorrect inhaler technique, poor adherence).

• Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen;- May be initiated by patient with written asthma action plan.

• Day-to-day adjustment;- For patients prescribed low-dose ICS/formoterol maintenance and

reliever regimen*

3. Stepping down asthma treatment;• Consider step-down after good control maintained for 3 months.• Find each patient’s minimum effective dose that controls both symptoms

and exacerbations.

General principles for stepping down controller treatment1. Aim

• To find the lowest dose that controls symptoms and exacerbations, and minimizes the risk of side-effects.

2. When to consider stepping down;• When symptoms have been well controlled and lung function stable for

≥3 months.• No respiratory infection, patient not travelling, not pregnant.

3. Prepare for step-down;• Record the level of symptom control and consider risk factors.• Make sure the patient has a written asthma action plan.• Book a follow-up visit in 1-3 months.

4. Step down through available formulations;• Stepping down ICS doses by 25–50% at 3 month intervals is feasible and

safe for most patients.

5. Stopping ICS is not recommended in adults with asthma.



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Non-pharmacological interventions1. Avoidance of tobacco smoke exposure;

• Provide advice and resources at every visit; advise against exposure of children to environmental tobacco smoke (ETS) in house, car, etc.

2. Physical activity;• Encouraged because of its general health benefits. Provide advice about

exercise-induced bronchoconstriction.

3. Occupational asthma;• Ask patients with adult-onset asthma about work history. Remove

sensitizers as soon as possible. Refer for expert advice, if available.

4. Avoid medications that may worsen asthma;• Always ask about asthma before prescribing NSAIDs or beta-blockers.

5. Breathing techniques (no specific technique);• May be a useful supplement to asthma medications.

6. (Allergen avoidance);• (Not recommended as a general strategy for asthma).

Indications for considering referral1. Difficulty confirming the diagnosis of asthma;

• Symptoms suggesting chronic infection, cardiac disease etc.• Diagnosis unclear even after a trial of treatment.• Features of both asthma and COPD, if in doubt about treatment.

2. Suspected occupational asthma;• Refer for confirmatory testing, identification of sensitizing agent, advice

about eliminating exposure, pharmacological treatment.3. Persistent uncontrolled asthma or frequent exacerbations;

• Uncontrolled symptoms or on-going exacerbations or low FEV1 despite correct inhaler technique and good adherence with Step 4.

• Frequent asthma-related health care visits.4. Risk factors for asthma-related death;

• Near-fatal exacerbation in past.• Anaphylaxis or confirmed food allergy with asthma.

5. Significant side-effects (or risk of side-effects);• Significant systemic side-effects.• Need for oral corticosteroids long-term or as frequent courses.

6. Symptoms suggesting complications or sub-types of asthma;• Nasal polyposis and reactions to NSAIDS (may be aspirin exacerbated

respiratory disease).• Chronic sputum production, fleeting shadows on CXR (may be allergic

bronchopulmonary aspergillosis).7. Additional reasons for referral in children 6-11 years;

• Doubts about diagnosis, e.g. symptoms since birth.• Symptoms or exacerbations remain uncontrolled.• Suspected side-effects of treatment, e.g. growth delay.• Asthma with confirmed food allergy.



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1. Check adherence with asthma medications Poor adherence;• Is very common: it is estimated that 50% of adults and children do not take

controller medications as prescribed.• Contributes to uncontrolled asthma symptoms and risk of exacerbations

and asthma-related death.

2. Contributory factors;• Unintentional (e.g. forgetfulness, cost, confusion) and/or • Intentional (e.g. no perceived need, fear of side-effects, cultural issues,

cost).

3. How to identify patients with low adherence;• Ask an empathic question, e.g. “Do you find it easier to remember your

medication in the morning or the evening?”, or “Would you say you are taking it 3 days a week, or less, or more?”

• Check prescription date, label date and dose counter.• Ask patient about their beliefs and concerns about the medication.

Strategies to improve adherence in asthmaOnly a few interventions have been studied closely in asthma and found to be effective for improving adherence;• Shared decision-making.• Simplifying the medication regimen (once vs twice-daily).• Comprehensive asthma education with nurse home visits.• Inhaler reminders for missed doses.• Reviewing patients’ detailed dispensing records.

Investigations in patients with severe asthma1. Confirm the diagnosis of asthma;

• Consider alternative diagnoses or contributors to symptoms, e.g. upper airway dysfunction, COPD, recurrent respiratory infections.

2. Investigate for co-morbidities;• Chronic sinusitis, obesity, GERD, obstructive sleep apnoea, psychological or

psychiatric disorders.

3. Check inhaler technique and medication adherence.

4. Investigate for persistent environmental exposure;• Allergens or toxic substances (domestic or occupational).



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Management of severe asthma1. Optimize dose of ICS/LABA;

• Complete resistance to ICS is rare.• Consider therapeutic trial of higher dose.

2. Consider low dose maintenance oral corticosteroids;• Monitor for and manage side-effects, including osteoporosis.

3. Add-on treatments without phenotyping;• Theophylline, LTRA – limited benefit.• Tiotropium – not yet approved for asthma by a major regulator.

4. Phenotype-guided treatment;• Sputum-guided treatment to reduce exacerbations and/or steroid dose.• Severe allergic asthma: suggest add-on anti-IgE treatment (omalizumab).• Aspirin-exacerbated respiratory disease: consider add-on LTRA.

5. Non-pharmacological interventions;• Consider bronchial thermoplasty for selected patients.• Comprehensive adherence-promoting program.

Managing exacerbations in primary carePrincipals;1. Repetitive bronchodilator with rapid-acting ß2-agonist.2. Oxygen supplementation.3. Systemic glucocorticosteroids.4. According to severity of asthma exacerbations.5. Aims;

• Prevent death from acute respiratory failure.• Relieve airway obstruction.• Relieve hypoxaemia.• Restore patient’s clinical condition & lung function to normal as soon as

possible.• Maintain optimal lung function & prevent early relapse.• Plan avoidance of future relapse.• Develop an action plan in case of further exacerbation.



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Managing exacerbations in primary care

Managing exacerbations in primary careSystemic glucocorticosteroids;• Speed resolution of exacerbations.• Prevent early relapse.• IV Hydrocortisone 200 mg or IV Methylprednisolone 40 mg.• Oral glucocorticosteroids as effective as IV & preferred because less invasive &

less expensive.• Oral glucocorticosteroids require at least 4 hours to produce clinical

improvement.• Oral glucocorticosteroids dose of 0.5 – 1 mg/kg for 3 – 5 days (children) or 7

days (adult).



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Identify patients at risk of asthma-related death1. Patients at increased risk of asthma-related death should be identified;

• Any history of near-fatal asthma requiring intubation and ventilation.• Hospitalization or emergency care for asthma in last 12 months.• Not currently using ICS, or poor adherence with ICS.• Currently using or recently stopped using OCS (indicating the severity of

recent events).• Over-use of SABAs, especially if more than 1 canister/month.• Lack of a written asthma action plan.• History of psychiatric disease or psychosocial problems.• Confirmed food allergy in a patient with asthma.

2. Flag/Tag these patients for more frequent review.

Written asthma action plans1. All patients should have a written asthma action plan;

• The aim is to show the patient how to recognize and respond to worsening asthma.

• It should be individualized for the patient’s medications, level of asthma control and health literacy.

• Based on symptoms and/or PEF (children: only symptoms).

2. The action plan should include;• The patient’s usual asthma medications.• When/how to increase reliever and controller or start OCS.• How to access medical care if symptoms fail to respond

3. Why? • When combined with self-monitoring and regular medical review, action

plans are highly effective in reducing asthma mortality and morbidity.

Written asthma action plans – medication options1. Increase inhaled reliever;

• Increase frequency as needed.• Adding spacer for pMDI may be helpful.

2. Early and rapid increase in inhaled controller;• Up to maximum ICS of 2000mcg BDP/day or equivalent.• Options depend on usual controller medication and type of LABA.

3. Add oral corticosteroids;• Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days.• Children: 1-2mg/kg/day up to 40mg, usually 3-5 days.• Morning dosing preferred to reduce side-effects.• Tapering not needed if taken for less than 2 weeks.



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Written asthma action plans

Follow-up after an exacerbation1. Follow up all patients regularly after an exacerbation, until symptoms and lung

function return to normal;• Patients are at increased risk during recovery from an exacerbation.

2. The opportunity;• Exacerbations often represent failures in chronic asthma care,

and they provide opportunities to review the patient’s asthma management.

3. At follow-up visit(s), check;• The patient understands of the cause of the flare-up.• Modifiable risk factors, e.g. smoking.• Adherence with medications, and understanding of their purpose.• Inhaler technique skills.• Written asthma action plan.

Symptom patterns in children ≤5 years



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Features suggesting asthma in children ≤5 years

Common differential diagnoses of asthma in children ≤5 years



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Common differential diagnoses of asthma in children ≤5 years (continued)

GINA assessment of asthma control in children ≤5 years (appendix 1: Management of asthma at primary care level)

Control-based asthma management cycle in children ≤5 years



SLIDE 59 Stepwise approach to control symptoms and reduce risk

(children ≤5 years)



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Stepwise approach – key issues (children ≤5 years)

1. Assess asthma control;• Symptom control, future risk, comorbidities.

2. Self-management;• Education, inhaler skills, written asthma action plan, adherence.

3. Regular review;• Assess response, adverse events, establish minimal effective treatment.

4. Other;• (Where relevant): environmental control for smoke, allergens, indoor or

outdoor air pollution.

Step 1 (children ≤5 years) – as-needed inhaled SABA

1. Preferred option: as-needed inhaled SABA;• Provide inhaled SABA to all children who experience wheezing episodes.

2. Other options;• Oral bronchodilator therapy is not recommended (slower onset of action,

more side-effects).• For children with intermittent viral-induced wheeze and no interval

symptoms, if as-needed SABA is not sufficient, consider intermittent ICS. Because of the risk of side-effects, this should only be considered if the physician is confident that the treatment will be used appropriately.



SLIDE 62 Step 2 (children ≤5 years) – initial controller + as-needed SABA

1. Indication;• Child with symptom pattern consistent with asthma, and symptoms not

well-controlled,or≥3exacerbationsperyear.• May also be used as a diagnostic trial for children with frequent wheezing

episodes.

2. Preferred option: regular daily low dose ICS + as-needed inhaled SABA;• Givefor≥3monthstoestablisheffectiveness,andreviewresponse.

3. Other options depend on symptom pattern;• (Persistent asthma) – regular leukotriene receptor antagonist (LTRA) leads

to modest reduction in symptoms and need for OCS compared with placebo.• (Intermittent viral-induced wheeze) – regular LTRA improves some

outcomes but does not reduce risk of exacerbations.• (Frequent viral-induced wheeze with interval symptoms) – consider

episodic or as-needed ICS, but give a trial of regular ICS first.



SLIDE 63 Step 3 (children ≤5 years) – medium dose ICS + as-needed inhaled SABA

1. Indication;• Asthma diagnosis and symptoms not well-controlled on low dose ICS.• First check symptoms are due to asthma, and check adherence, inhaler

technique and environmental exposures.

2. Preferred option: medium dose ICS with as-needed inhaled SABA;• Review response after 3 months.

3. Other options;• Consider adding LTRA to low dose ICS (based on data from older children).



SLIDE 64

SLIDE 65

Step 4 (children ≤5 years) – refer for expert assessment

1. Indication;• Asthma diagnosis and symptoms not well-controlled on medium dose ICS.• First check symptoms are due to asthma, and check adherence, inhaler

technique and environmental exposures.

2. Preferred option: continue controller treatment and refer for expert assessment.

3. Other options (preferably with specialist advice);• Higher dose ICS and/or more frequent dosing (for a few weeks).• Add LTRA, theophylline or low dose OCS (for a few weeks only).• Add intermittent ICS to regular daily ICS if exacerbations are the main

problem.• ICS/LABA not recommended in this age group.

‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years

§ This is not a table of equivalence.§A low daily dose is defined as the dose that has not been associated

with clinically adverse effects in trials that included measures of safety.



SLIDE 66

SLIDE 67

Choosing an inhaler device for children ≤5 years

Initial assessment of acute asthma exacerbations in children ≤5 years

*Any of these features indicates a severe exacerbation.**Oximetry before treatment with oxygen or bronchodilator.† Take into account the child’s normal developmental capability.



SLIDE 68

SLIDE 69

Indications for immediate transfer to hospital for children ≤5 years

Initial management of asthma exacerbations in children ≤5 years



SLIDE 70 Management of acute exacerbation at primary care level





UPDATE ON MANAGEMENT OF ASTHMA AND ASSESSMENT TOOL


TOPIC 2



SLIDE 2

SLIDE 1

Poorly managed asthma

• 52year-oldtaxidriver• Asthmasinceinfancy• Uptoage13yearsold: – Theophylline syrup – Prednisone syrup as needed – Salbutamol pMDI 3X/day & as

needed

• Pulmonary tuberculosis!! Spinalsurgery for osteoporosis and scoliosis

• 42to52yearsold – FEV1 45% predicted; minimal

reversibility – Budesonide 800g/day pMDI – Salbutamol pMDI as needed – Salmeterol 50µg bid pMDI

Learning objective

• Brief update forhealth careprovideronasthmaassessment tools,management targetof asthmatreatment and control.

UPDATE ON MANAGEMENT OF ASTHMA AND ASSESSMENT TOOL

Definition of Asthma

• Asthma–chronicdiseasecausedbyinflammationoftheairways.

• Definition - Asthma is a heterogeneous disease, usually characterizedby chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.

TOPIC 2: UPDATE ON MANAGEMENT OF ASTHMA AND ASSESSMENT TOOLTRAINING MODULE FOR HEALTH CARE PROVIDERS



SLIDE 5

Poor Adherence Factors

I Unintentional non-adherence

1. Inadequate understanding of disease

2. Poor comprehension of drug regimen or inhaler technique5

3. Simple forgetfulness

4. Socioeconomic factors

II Intentional non-adherence

1. Patient’s understanding of health benefits

2. Ethnic/cultural differences

Asthma and Allergic Rhinitis: 2 Related Conditions linked by 1 Common Airway

1. Frequently overlapping conditions

2. Involvement of similar tissues

3. Common inflammatory processes

• Commoninflammatorycells

• Commoninflammatorymediators

SLIDE 4

Reasons for Poor Control in Asthma

1. The wrong diagnosis

2. Incorrect choice of inhaler, poor technique

3. Smoking

4. Co-morbid rhinitis

5. Individual variation in response to treatment

6. Patients’ beliefs and adherence

* Lack of treatment adherence is a major problem for asthma management



SLIDE 8

Using the adult ACT score (appendix 1 chapter topic 1)

SLIDE 7

SLIDE 6 Rationale for Development

1 Asthma management guidelines now recommend the early use of inhaled steroids in the majority of patients with asthma

2. Patients remaining symptomatic while on inhaled steroid treatment may need a change in therapy. Options:

• IncreasedoseofICS

• SwitchICS/LABAcombinationtherapy

• Whatarethebenefitsofcombininganinhaledsteroidwithaninhaledlong-acting bronchodilator ?

• Moreeffectivethanincreasingtheinhaledsteroiddose

• Greaterimprovementsinlungfunction,symptomcontrol,reductioninexacerbation and quality of life

What does control really mean?

New 2010 GINA guideline definition of control – a gold standard

Characteristic Controlled (all of the following)

Daytime symptoms Twice or less per week

Limitations on activities None

Nocturnal symptoms or awakenings None

Need for reliever/‘rescue’ treatment Twice or less per week

Lung function Normal

ACT score Level of control

20 - 25 Good

15 - 19 Inadequate

10 - 14 Poor

5 - 9 Very Poor



SLIDE 11

SLIDE 10

Goal of management of asthmaSLIDE 9

Overall asthma control

AchievingCURRENT CONTROL

Defined by

Defined by

Symptoms

Activity

Instability / worsening

Loss of lung

function

Reliever use

Lung function

Exacerbations

Adverse effects of

medication

ReducingFUTURE

RISK

Outcome: Tampin Health Clinic 2009 – 2012

Conclusions1. Poor asthma control worsens patient’s quality of life2. Deaths and hospital costs reduced with improved control3. Control can be achieved in line with guidelines, benefiting patient’s quality

of life4. Asthma control instruments have predictive validity5. Poor asthma control score associated with:

• Bigimpactonpatient’slife • Increasedexacerbations,admissionsanddoctorvisits



ASSESSMENT AND MONITORING ASTHMA AND CLINICAL ACTION PLAN


TOPIC 3



Global Initiative for Asthma Management (GINA)

The assessment of asthma control should include control of clinical manifestations and control of expected future risk such as exacerbation, accelerated decline in lung function and side effects of treatment

A. Assessment of current clinical control (preferably over the past 4 weeks)

B. Assessment of future risk ( Risk of exacerbations, instability, rapid decline in lung function and side effects ):

• Featuresofincreaseriskofadverseeventinthefuture:poorclinicalcontrol, frequent exacerbations in past years, ever admissions to critical care for asthma, low FEV1, exposure to cigarette smoke, high dose medications

SLIDE 2

SLIDE 1 1. GINA : Adult & pediatric (appendix 1 – chapter 1, topic 1)

2. Asthma Control Test (ACT) : Adult & pediatric (appendix 1 – chapter 1, topic 1)

3. PEFR normogram: Adult & pediatric (appendix 1 – chapter 1, topic 3)

4. Clinical action plan : Adult & pediatric

Learning objective

• UpdateonthelatestGINA2014classificationforadultandpaediatricgroup(agebelow5yearsold),asthma control test (ACT) monitoring for adult and children (4 to 11 years old), normogram for adult and paediatric group and clinical action plan for adult and paediatric group which are the most important tools upon discharging patient.

• Allthemonitoringtoolsareupdatedandcanbeusedfortheassessment,monitoringandadjustingthemedication dose for asthmatic patient. Paramedic may use these tools during triaging the patient and it is useful in managing the asthma controlled level and also emergency cases.

ASSESSMENT AND MONITORING ASTHMA AND CLINICAL ACTION PLAN

TOPIC 3: ASSESSMENT AND MONITORING ASTHMA AND CLINICAL ACTION PLANTRAINING MODULE FOR HEALTH CARE PROVIDERS



SLIDE 3 PEFR normogram: Adult

PEFR normogram: PediatricSLIDE 4


MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers

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MANAGEMENT OF CHILDHOOD ASTHMA ACCORDING TO MALAYSIA CPG


TOPIC 4



Overview of Pathogenesis of AsthmaSLIDE 2

Learning outcomes1. Understand about pre - school wheeze

2. Diagnosing asthma in children

3. Able to classify asthma severity upon diagnosis and treatment

4. Understand about asthma control

5. Understand stepwise approach of treatment

6. Able to classify and recognize severity of asthma exacerbation

SLIDE 1

MANAGEMENT OF CHILDHOOD ASTHMA ACCORDING TO MALAYSIA CPG

Learning Objective

• Brief regardingthe latestmanagementflowofasthmatreatment inpaediatricwhichbasedonthelatest Asthma Management in children (Malaysia).

• Clinicalassessment,evaluationofasthmacontrolandlongtermmanagementstepofmedicationisupdated.

• Monitoring instrumentuse inchildrensuchaspeakflowmeter (PFM)andPulmonaryfunctiontest(Spirometry) is mentioned in this topic.

• Drug dosage formulary and inhaler use is illustrated in this topic for better demonstration andunderstanding

TOPIC 4: MANAGEMENT OF CHILDHOOD ASTHMA ACCORDING TO MALAYSIA CPGTRAINING MODULE FOR HEALTH CARE PROVIDERS

Pathogenesis

Management

Genetic Environment Preventive measures

Airway inflammation Asthma Controllers

AHR Baseline airway obstruction

Asthma exacerbation

Asthma relievers

Triggers: • Virus • Allergens

• Irritants

Environmental controls

Overall asthma control



SLIDE 4

Differential diagnosis of asthma

Airway Remodeling (refer to appendix 1: Chapter 1, Topic 3 ; illustrative regarding the chronic airways inflammation and airway remodeling)

• Structuralchangesseeninpatientwithrespiratorydisease

• Maincomponents

1. Epithelial damage and disruption

2. Goblet cells hyperplasia

3. Increase number of sub mucous gland

4. Deposition if structural protein into the reticular

• basementmembrane

• Hypertrophyandhyperplasiaofsmoothmuscle

• Subepithelialfibrosis

• Increasedvascularization

Upper airway disease Allergic Rhinitis / Rhinosinusitis / Sinusitis

Obstruction of Large Airways

• Foreign body in trachea and bronchus• Vocal cord dysfunction• Vascular rings• Laryngeal webs• Laryngo-tracheomalacia, tracheal stenosis,

bronchostenosis• Enlarged lymph nodes

Obstruction of Small Airways

• Viral Bronchiolitis• Obliterative bronchiolitis• Bronchiectasis • Heart disease/ heart failure• Chronic lung disease / Bronchopulmonary

dysplasia• Cystic fibrosis

Other causes• Recurrent cough due to GORD• Aspiration from dysfunctional swallowing• Immunodeficiency

Upper airway disease • Allergic Rhinitis / Rhinosinusitis• Sinusitis



SLIDE 6

Pattern of wheeze

SLIDE 5 Asthma wheeze

Wheeze with ARI < 3 years

Persistent wheeze

YES YES NO

NO YES YES

CHILDHOOD WHEEZING

(50%)

Transient early

wheeze (20%)

Late onsetwheezes

(15%) N= 1246

Ref: Martinoz FD New England J Med 1995: 332:133.8

Persistent wheeze(15%)

Term Definition

Episodic viral wheeze Wheeze during discrete times in association with clinical evidence of viral cold absence of wheeze between episodes

Multiple trigger wheeze Wheeze that shows discrete exacerbationsSymptomatic in between episodes

Duration of wheezeTransient wheeze

• Commenced before the age of three years and retrospectively found to disappear by 6 years old.

• Transient wheeze can be episodic wheeze or multiple trigger wheeze

Temporal pattern of wheezeTerm Definition

Persistent wheeze Symptoms (retrospectively) to have continued until the age of > 6 years oldMay be episodic or multiple trigger wheeze

Late onset of wheeze Starts after the age of three years.Late onset wheeze may be episodic or multiple trigger wheeze



SLIDE 8

Long term management of Persistent Asthma

Evaluation of background of newly diagnosed asthmaSLIDE 7Intermittent Asthma

1. Daytime symptoms < once a week2. Nocturnalsymptoms≤twiceamonth3. No exercise induced symptoms.4. Brief exacerbations not affecting sleep and activity

Persistent Asthma

Mild

• Daytimesymptoms≥onceaweek• Nocturnal symptoms > twice a month• Exacerbation affecting sleep and activity once a month.• PEFR or FEV1 >80%• Exercise or activity induced asthma

Moderate

• Daytime symptoms daily• Nocturnal symptoms > once a week• Exacerbationaffectingsleepandactivity≥twiceamonth• PEFR or FEV1 60% - 80%• Exercise or activity induced asthma

Severe

• Daily daytime symptoms• Daily nocturnal symptoms • Exacerbation affecting sleep and activity frequently• PEFR or FEV1 < 60%• Exercise or activity induced asthma

STEP 1 Intermittent

STEP 2 Mild persistent

asthma

Low dose inhaled steroids or leukotriene antagonist

STEP 3 Moderate persistent

asthma

Moderate dose of inhaled corticosteroids

STEP 4 severe persistent asthma

Moderate dose of inhaled corticosteroids combination / high dose inhaled corticosteroids

STEP 5 severe persistent asthma

Add theophylline / alternate day corticosteroids

INTERMITTENT

2 AGONIST



SLIDE 9 Evaluation of asthma control

A. Symptom control Level of asthma symptom control

In the past 4 weeks, the child had: Well controlled

Partly controlled Uncontrolled

Daytime asthma symptoms for more than few minutes, more than once / week

Yes No

None of these 1 – 2 of these 3 – 4 of these

Any activity limitation due to asthma? (runs, plays less than other children)

Yes No

Reliever needed* more than once a week?

Yes No

Any night waking or night coughing due to asthma

Yes No



SLIDE 10 Stepwise approach – key issues (children ≤ years)



SLIDE 13

SLIDE 14

SLIDE 12

Pulmonary Function Test: Spirometry1. At the time of initial assessment

2. After treatment initiated and stabilization of symptoms

3. To document a near normal attainment of lung function

4. When there is loss of control

5. At least yearly to document maintenance of lung function

6. More frequent if clinically indicated

Spirometry

Three basic measurements:

1. Forced Vital Capacity (FVC)

2. Forced Expiratory Volume In One Second (FEV1)

3. Ratio of FEV1/FVC (Forced Expiratory Ratio FER or FEV1 %)

Long Term Follow-up

Management Approach Based On control

Level of Control Treatment options

Controlled Maintain and find lowest controlling step

Partially controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbations Treat as exacerbations

INCREASE

REDUCE

• Assessment-asthmacontrol based

• Compliance• Asthmaeducation

• Frequencyandseverityofacuteexacerbation• Morbiditysecondarytoasthma• Qualityoflife• PeakExpiratoryFlowRate(PEFR)orFEV1monitoring• Frequency• Technique • Understandingasthmainchildhood• Reemphasizecompliancetotherapy• Writtenasthmaactionplan

INCR

EASE

REDU

CE

SLIDE 11



SLIDE 3

SLIDE 16

SLIDE 17

Reliever

Relieve respiratory symptoms

1. Reliever : intermittent short acting B2 agonist drug of choice

2. Oral bronchodilator discouraged

Preventer1. Reduce airway inflammation inhaled

corticosteroids treatment of choice

2. Leukotrienes antagonist

3. Age of child

4. Asthma wheeze phenotypes

5. Frequency and severity of symptoms

Calculations

Peak flow rate (PEFR) measurement

1. Based on patient’s height and gender,

• identifythepredictedPEFRvalue

• i.e.x(ReferPEFRforMalaysianchildren)

2. Take the best patient’s PEFR measurement i.e. y

3. Calculation PEFR percentage: ( y/ x ) x 100% = z %

4. Classification of severity (refer Asthma severity and control)

Bronchodilator response

1. Best pre- bronchodilator PEFR i.e. a

2. Best post-bronchodilator PEFR i.e. b

3. Calculate percentage of bronchodilator response

(b-a) x 100 = c % a

Peak Flow Meter1. A tool for monitoring ongoing monitoring

2. Useful for children who can perform Peak Flow Meter

3. To detect early changes in disease states that require treatment

4. Evaluate responses to changes in therapy

5. Afford a quantitative measure of impairment

SLIDE 16



Assessment of asthma exacerbations

1. History and physical examination is an important tool to assess the severity of asthma

2. The time of onset of the exacerbation

3. To identify underlying cause of the present exacerbation such as URTI, cigarette smoker and etc

4. Severity of symptoms including exercise and sleep disturbance

5. All current asthma medications that the patient has been on prior to the exacerbation

6. The dose of preventer therapy taken during the deterioration

7. Patient’s response to therapy during the exacerbation such as to the dose of bronchodilator or oral steroids taken.

8. Risks factors: Past history of hospitalizations, intensive care, ER visits due to exacerbations

SLIDE 20

Inhaler devices according to ageSLIDE 19

Controller medications

Controller medication: Shown to have better control with no night symptoms, no increase in short acting B2 agonist use.

1. Seretide (Flixotide + Salmeterol)

2. Symbicort (Pulmicort)

Children aged 0 - 6 years Metered dose inhaler + spacer with facemask

Children aged > 6 years •Metereddoseinhaler+spacerwithfacemask•Metereddoseinhaler+spacerwithmouthpiece•Drypowderinhaler•Breathdevice(>8years)

SLIDE 18



SLIDE 22

Management based on severity

Assessment of severity of acute asthma

Mild Moderate Severe

Altered consciousness No No Yes

Physical exhaustion No No Yes

Talks in Sentences Phrases Words

Central cyanosis Absent Absent Present

Rhonchi on auscultation Present Present Absent

Accessory muscle use Absent Moderate Marked

Sternal recession Absent Moderate Marked

Iniatial PEFR >60% 40-60% <40%

Pulse oximetry in air >93% 91-93% <90%

Severity Treatment Observation Plan

Mild Nebulized salbutamol or MDI salbutamol + spacer (4 – 6 puffs, < 6 yo) and 8 – 12 puffs, > 6 yo)

Oral prednisolone 1 mg / kg / day (max: 60 mg perday for 3 – 5 days as moderate)

Observe for 60 minutes after last dose

Discharge with improved long term treatment and asthma plan

Short course of oral steroid (3 – 5 days)

Regular bronchodilator 4 – 6 hourly for few days then PRN

Early TCA 2 – 4 weeks

Review after 20 minutes, if no improvement treat as moderate

Moderate Nebulised salbutamol ± ipratropium bromide (3 at 20 minutes intervals), oxygen at 8 liters/ min via face mask and Oral prednisolone 1 mg / kg / day (max: 60 mg perday for 3 – 5 days

Observe for 60 minutes after last dose

Discharge with improved long term treatment and asthma planShort course of oral steroid (3 – 5 days)Regular bronchodilator 4 – 6 hourly for few days then PRNEarly TCA 2 – 4 weeks

Admit if no improvement

Severe / life threatening

Nebulised β2 agonist every 20 minutes / continous for 1 hour.Ipratropium bromide 3x every 20 minutesOxygen (face mask 8 liters)Steroids (oral / IV)IV salbutamol cntinous infusion 1 – 5mic/kg/min ± loading 15 mic/ kg over 10 minutesSubcutaneous β2 agonist (terbutraline / adrenaline) IV bolus magnesium sulphate 50% 0.1 ml/kg (50mg/kg) over 20 minutesConsider HDU / ICU admission± IV aminiphylline± Ventilation

Continue observation and review

SLIDE 21



SLIDE 24

Conclusion1. Correct diagnosis

2. Classification of severity

3. Classification of asthma control

4. Appropriate medication

5. Recognizing high risk asthmatics

High risk of asthma group

Poor asthma control

On threemedications

Bronchodilator reliance

Immediate asthma symptoms orhypersensitivity to drugs or food

Poor perceivers and denials

Nocturnal symptoms

Undertreatedand poor adherence

Frequent ER visitsand admissions

ICU / HDU admission and ventilations

CHILDHOOD WHEEZING

(50%)

SLIDE 23


STEPWISE APPROACH, INHALER TECHNIQUE AND PHARMACOTHERAPY IN ASTHMA MANAGEMENT


TOPIC 5



SLIDE 1 Stepwise Approach

Goal Of Therapy : Control Of AsthmaFor most asthmatic patients, the situation can be extremely well-controlled by using the step-care approach as recommended by NAEPP in 2007

Koda-Kimble M.A., Young L.Y., Alldredge B.K., Corelli R.L., Guglielmo B.J., Kradjan W.A. et al. (2009). Applied therapeutics: the clinical use of drugs. 9th ed. Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.

Stepwise approach for managing asthma in youth > 12 years of age and adults

INHALER TECHNIQUE AND PHARMACOTHERAPY IN ASTHMA MANAGEMENT

Learning Objective

• Listofcontrollerandpreventivemedicationarementionedinthistopicforbetterunderstanding.Side effect of each medication is stated in this module for better practice and learning purposes.

• Adjustmedication&dosagebasedtothelevelofasthmamanagement.Learntherighttechniqueinusing inhaler and peak flow meter with better illustrtive.

TOPIC 5: STEPWISE APPROACH, INHALER TECHNIQUE AND PHARMACOTHERAPY IN ASTHMA MANAGEMENTTRAINING MODULE FOR HEALTH CARE PROVIDERS

Intermittent Asthma

Persistent Asthma: Daily MedicationConsult with asthma specialist if Step 4 care or higher is required.

Consider consultation at Step 3

STEP 1Preferred:

SABA PRN

STEP 2Preferred:

Low-dose ICSAlternative:Cromolyn,

LTRA, Nedocromil

or Theophylline

STEP 3Preferred:

Low-dose ICS + LABA

ORMedium-dose ICS

Alternative:Low-dose

ICS + either LTRA,

Theophylline or Zileuton

STEP 4Preferred: Medium-

dose ICS + LABA

Alternative:Medium-

dose ICS + either LTRA, Theophylline or Zileuton

STEP 5Preferred:

High-dose ICS + LABA

ANDConsider

Omalizumab for patients

who have allergies

STEP 6Preferred: High-

dose ICS + LABA + oral corticosteroid

ANDConsider

Omalizumab for patients who have

allergies

Each step: Patient education, environmental control and management of comorbidities.Step 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes).

Quick-Relief Medication for All Patients• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to

3 treatments at 20-minutes intervals as needed. Short course of oral systemic corticosteroids may be needed.

• Use of SABA > 2 days a week for symptom relief (not prevention of IEB) generally indicates inadequate control and the need to step up treatment.

Notes:• The stepwise approach is meant to assist, not replace, the clinical decision making required to

meet individual patient needs.• If alternative treatment is used and response is inadequate, discontinue it and use the preferred

treatment before stepping up.• Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the need

to monitor liver function. Theophylline requires monitoring of serum concentration levels.• In step 6, before oral systemic corticosteroids are introduced, a trial of high-dose ICS + LABA +

either LTRA, theophylline or zileuton may be considered, although this approach has not been studied in clinical trials.

Step up if needed

(first check adherence,

environmental control and comorbid

conditions)Step down if possible (and

asthma is well controlled at least 3 months)

AssessControl

Adapted from NAEPP 2007



Goal Of Therapy : Control Of Asthma

This stepwise approach combining the four components of care in the management of asthma that emphasizes pharmacological treatment is started based on the classification of asthma severity

Koda-Kimble M.A., Young L.Y., Alldredge B.K., Corelli R.L., Guglielmo B.J., Kradjan W.A. et al. (2009). Applied therapeutics: the clinical use of drugs. 9th ed. Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.

SLIDE 2

CLASSIFICATION FEATURES

Intermittent •Symptomslessthanonceaweek•Briefexacerbations•Nocturnalsymptomsnotmorethantwiceamonth•FEV1orPEF≥80%predicted•PEForFEV1 variability < 20%

Mild Persistent •Symptomsmorethanonceaweekbutlessthanonceaday•Exacerbationsmayaffectactivityandsleep•Nocturnalsymptomsmorethantwiceamonth•FEV1orPEF≥80%predicted•PEForFEV1 variability < 20 – 30%

Moderate Persistent •Symptomsdaily•Exacerbationsmayaffectactivityandsleep•Nocturnalsymptomsmorethanonceaweek•Dailyuseofinhaledshort-actingβ2-agonist•FEV1 or PEF 60-80% predicted•PEForFEV1 variability > 30%

Severe Persistent •Symptomsdaily•Frequentexacerbations•Frequentnocturnalasthmasymptoms•Limitationofphysicalactivities•FEV1orPEF≤60%predicted•PEForFEV1 variability > 30%

FEV1: forced expiratory volume in one second; PEF: peak expiratory flow.



SLIDE 4

Asthma management

Stepwise approach is subdivided into increases or decreases in the dose medications within the class used by the patient including the addition or change of medication which will change the class of medications.

Stepped up change is further sub classified to either temporary or limited such as burst of oral systemic corticosteroids (OSC) for 3 to 10 days during an exacerbation or may be prescribed to improve longer-term control.

Yawn, B. P et al. (2007). Asthma treatment in a population-based cohort: putting step-up and step-down treatment changes in context. Mayo Clin Proc, 82 (4), 414-421

Changes in the brands of ICS in therapeutic categories were compared as (Yawn et al., 2007) listed in Table 3 which shows an estimated equipotent daily dose for adults.

Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention updated 2010.


Pharmacological treatment is based on the classification of adjusted (stepped up or stepped down) according to level of asthma control (Appendix 1; Chapter 1; Topic 5)

Koda - Kimble M.A et al. (2009). Applied therapeutics: the clinical use of drugs. 9th ed. Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.

Stepped up and stepped down therapy using asthma medications, also known as stepwise approach, can be done by gathering information from each appointment with clinicians.

Yawn, B. P et al. (2007). Asthma treatment in a population-based cohort: putting step-up and step-down treatment changes in context. Mayo Clin Proc, 82 (4), 414-421.



Table 3: Estimated equipotent daily doses of inhaled corticosteroids for adults+SLIDE 5

Drug Low daily dose (µg)

Medium daily dose (µg) High daily dose (µg)++

Beclomethasone dipropionate

200 – 500 >500 – 1000 > 1000

Budesonide* 200 – 400 >400 – 800 > 800

Ciclesonide* 80 – 160 >160 – 320 >320

Flunisolide 500 – 1000 >1000 – 2000 >2000

Fluticasone propionate

100 – 250 >250 – 500 >500

Mometasone furoate*

110 – 220 440 >440

Triamcinolone acetonide

400 – 1000 >1000 – 2000 >2000

+ Comparisons based upon efficacy data.++ Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side effects.* Approved for once-daily dosing in mild patients.

Notes• Themost importantdeterminantofappropriatedosing is theclinician’s judgementof the

patient’s response to therapy. The clinician must monitor the patient’s response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects.

• Designationoflow,mediumandhighdosesisprovidedfrommanufacturers’recommendationswhere possible. Clear demonstration of dose-response relationships is seldom provided or available. The principle is therefore to establish the minimum effective controlling dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse events.

• AsCFCpreparationsare taken from themarket,medication inserts forHPApreparationsshould be carefully reviewed by the clinician for the equivalent correct dosage.



SLIDE 6 Asthma Management

In order to achieve asthma control, the following sequence of activities is proposed:• First,forpatientswhodonottakethemedicationforlong-termcontrol,assessment

of asthma severity should be taken in advance and then start pharmacotherapy according to the severity.

• Forpatientswhohavebeentakinglong-termcontrolmedications,thelevelofasthmacontrol needs to be evaluated and pharmacotherapy is stepped up if asthma is poorly controlled on current therapy.

• However, before stepping the treatment up, patient’s compliance to medications,technique of handling inhaler and environmental control measures should be reviewed.

• Dependingontheinitiallevelofseverityorcontrol,asthmacontrolshouldbeevaluatedin two to six weeks.

• Ingeneral,thelevelofasthmacontrolshouldbeclassifiedbythemostsevereindicatorof impairment or risk.

• Riskdomainistypicallymorecloselyrelatedtomorbidityamongyoungchildrenfromthe impairment domain because young children are usually free of symptoms between exacerbations.

• If spirometry shows poorer control than other measures of impairment, cliniciansshould consider fixed obstacles and need to reassess the other steps.

• Thepharmacotherapyshouldbesteppedupifthefixedobstaclesstillfailtoexplainthe lack of control because low value of FEV1 is one predictor of exacerbations of asthma as well as the history of exacerbations suggests poor asthma control.

• ThecliniciansalsohavetoincludetheuseofOSCandreviewplansforhandlingofasthmaexacerbations especially for patients who have a history of severe exacerbations.

• A review should be carried out on the patient’s adherence to drugs, technique ofinhaler, environmental control measures or whether there are new disclosure and management of co-morbidities if a patient does not achieve asthma control by the above actions.

• Pharmacotherapycanbesteppeduponestepinnotwell-controlledasthmaortwosteps in very poorly controlled asthma if adherence and measures of environment control are sufficient.

• For patients using alternative treatment at the initial of treatment, it is necessaryto discontinue it and use the preferred treatment option before stepping up pharmacotherapy.

• TheOSC short-termuse canbe considered to gain faster control for patientswhoare experiencing an exacerbation at the time of assessment or whose asthma always interrupts normal daily activities or sleep.

• Cliniciansshouldconsideranalternativediagnosis if lackofcontrolpersists,beforestepping up further.

• For patients experiencing the side effects of pharmacotherapy, different treatmentoptions should be considered.

• It is important to have regular follow up tomaintain the asthma control becauseasthma can change from time to time.

• Patientsshouldbescheduledat1-to6-monthintervalsanditwilldependonfactorssuch as the level of treatment required and the level or duration of asthma control.

• Forwell-controlledasthma forat least3months, cliniciansshould considera stepdown in pharmacotherapy.

• Astepdowninpharmacotherapyisnecessarytoidentifytheminimumtherapyneededto maintain good asthma control.

• However,thereareonlyafewstudiesinguidingtherapyreductioninpharmacotherapythat should be gradual and closely monitored.

• Ingeneral,forevery3months,thedoseofICScanbereducedfrom25%to50%ofthelowest possible dose.

• For those patients who have asthma symptoms during particular seasons (e.g.,seasonal pollens, allergens or viral respiratory infections) or intermittent asthma for the rest of the year, clinicians should consider seasonal periods of long-term daily control of pharmacotherapy.

• Thisapproachisnotstrictlyassessedbutcloselymonitoredfortwotosixweeksafterpharmacotherapy is discontinued to assure sustainability control of asthma

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3. (October 2007). Guidelines for the Diagnosis and Management of Asthma. US Department of Health and Human Services. NIH Publication No. 08-5846.



SLIDE 8


Pharmacotherapy In Asthma Management

Bronchial Asthma• Airwayinflammation

• Episodic,reversiblebronchospasm

• Chronic inflammation that leads tomarked bronchial hyper - reactivity orhypersensitivity (cornerstone: inhaled corticosteroid, ICS)

• Exposure to allergen or trigger factors (extrinsic or intrinsic factors) → stimulate a broncho - constrictive response

- Humidity, temperature changes, smoke, fumes, stress, emotional upset, allergies, dust, food, some drugs

• ReleaseofseveralmediatorsfromIgE-sensitizedmastcellsandothercellsinvolved in immunologic responses

• Mastcellsstimulatereleaseofchemicalmediators (histamines,cytokines,serotonin, ECF-A (eosinophils))

• Thesechemicalmediatorsstimulate: - bronchial constriction - mucous secretions - inflammation - pulmonary congestion

SLIDE 7

Reduce impairment

• Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the daytime, in the night or after exertion)

• Require infrequent use (< 2 days a week) of inhaled SABA for quick relief of symptoms (not including prevention of exercise-induced bronchospasm [EIB])

• Maintain (near) normal pulmonary function

• Maintain normal activity levels (including exercise and other physical activity and attendance at school or work)

• Meet patients’ and families’ expectations of and satisfaction with asthma care

Reduce risk

•Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalisations

• Prevent loss of lung function; for children, prevent reduced lung growth

• Provide optimal pharmacotherapy with minimal or no adverse effects of therapy



Controller medications1. Keeps swelling and mucus from developing in the airways

2. Must be taken EVERY day even when not having symptoms

3. Inhaled corticosteroids (ICS’s) are the most common and effective way to control asthma

4. Help prevent asthma exacerbations from developing.

SLIDE 11

SLIDE 10

Previously GINA classified three major classes for asthma treatment: 1. ß-agonist such as salbutamol, salmeterol or terbutaline; 2. glucocorticoids such as beclomethasone ; and 3. (3) inhibitors of the cysteinyl-leukotriene (cLI) pathway such as montelukast,

zafirlukast or zileuton.

However, the asthma treatment was revised and classified as short-term management (reliever) and long-term management (controller), where cLI was put under controller (GINA, 2009).

Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention updated 2009. (2009). 1. Reliever drugs [short acting ß-agonist (SABA) such as salbutamol] are

delivered as inhalers and are usually adequate for mild intermittent asthma. 2. SABA is used because it can provide rapid ‘rescue’ for acute airway

obstruction 3. ICS, long acting ß-agonist (LABA) and cLI were classified as controller drugs

in addition to rescue medication and it is necessary for mild, moderate or severe persistent asthma.

4. This is because the controller drugs would modify the airway environment; hence reducing the number of acute airway narrowing in the more symptomatic patients.

Silverman, E. S., Liggett, S. B., Gelfand, E. W., Rosenwasser, L. J., Baron, R. M., Bolk, S. et al. (2001). The pharmacogenetics of asthma: a candidate gene approach. The Pharmacogenomics Journal, 1, 27-37.

General treatment principles in view to achieve these goals of therapy with four major components of care in the management of asthma control including 1. measures of asthma assessment and monitoring; 2. education for a partnership in care; 3. control of environmental factors and co-morbid conditions that affect

asthma; and 4. medications

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, Expert Panel Report 3. (October 2007). Guidelines for the Diagnosis and Management of Asthma. US Department of Health and Human Services. NIH Publication No. 08-5846.

SLIDE 9



SLIDE 12

SLIDE 13

Possible Side Effects

Anti-inflammatory - Glucocorticorsteroid

Remember

1. Steroids are meant to work over a period of time to reduce swelling of the airways.

2. They must be used regularly to be effective.

Always take steroids exactly as your doctor directs, even when you feel better or do not believe they are helping you. If you stop taking steroids, your breathing can get worse, sometimes much worse.

Systemic Steroids (taken by mouth as a pill; affects the entire body)

Inhaled Steroids

May notice after a few days:•Fluidretention•Increasedappetite

May experience after severalmonths of use:• Adrenal suppression (less able to handle

stress)• Decreased resistance to infection (get

infections more easily)

May experience after severalmonths or years of use:•Moonface•Cataracts•Excessfacialhair•Osteoporosis

• Oral thrush (yeast infection of the mouth) and sore tongue

• Hoarseness

SLIDE 14

Leukotrine Receptor Antagonists & Synthesis Inhibitors1. Montelukast sodium (Singulair); Zafirlukast (Accolate)

2. Action - Decreases the inflammatory process

3. Use - prophylactic & maintenance drug therapy for asthma

4. Montelukast: • NewLeukotrieneReceptorAntagonist • ShortT1/2(2.5-5.5hours) • SafeForChildrenUnder6YearsOld.

5. Leukotriene (LT) a chemical mediator that can cause inflammatory changes in the lung.

• Thegroupcysteinyl leukotrienespromoteand increase ineosinophilmigration, mucus production, and airway wall edema, which result in bronchoconstriction.

6. LT receptor antagonists & LT synthesis inhibitors (Leukotriene modifiers) effective in reducing the inflammatory symptoms of asthma triggered by allergic & environmental stimuli - Not for acute asthma



SLIDE 17 Adrenergic Bronchodilators

1. The most effective bronchodilators

2. Mechanism of action (MOA): • Alpha receptor stimulation which causes vasoconstriction and

vasopressor effect • Beta-1 receptor stimulation causes increases heart rate (HR) and

myocardial contractility • β2-adrenergic receptor stimulate adenyl cyclase and increasing

cyclic adenosine monophosphate (cAMP) in smooth muscle cells bronchodilatation (muscle relax)

3. Almost given exclusively by inhalation: • Decreasesthesystemicdoseandadverseeffects • Occasionallybynebuliser

4. Aerosol administration: • Enhancesbronchoselectivity • Providesamorerapidresponse • Greater protection againts provocations that induce bronchospasm

(e.g. exercise, allergen challenges) than does systemic administration

What kinds of bronchodilators are there?1. Bronchodilators may be: • Endogenous(originatingnaturallywithinthebody)or • Medicationsadministeredforthetreatmentofbreathingdifficulties • Somebronchodilatorsalsohelpclearmucusfromthelungsandreduce

inflammation.

2. Many different kinds of bronchodilators are available.

3. They can be grouped according to how long they work (called short- and long-acting drugs) or the way in which they widen or dilate the airways beta-agonists, anticholinergics or theophyllines).

4. They can be grouped according to how long they work (called short- and long-acting drugs) or the way in which they widen or dilate the airways beta-agonists, anticholinergics or theophyllines).

5. While all bronchodilators widen the airways, they work in different ways to do so.

6. It is therefore possible to combine bronchodilators in order to achieve maximal benefit.

SLIDE 16

SLIDE 15

Introduction1. Bronchodilators are medications that: • relax/dilatesthebronchiandbronchialmuscles • decreasingresistanceintherespiratoryairway • increasingairflowtothelungs

2. Relaxing these muscles makes the airways larger, allowing air to pass through the lungs easier.

3. This helps people with asthma breathe better.



SLIDE 18 Adrenergic Bronchodilators : SABA

Salbutamol1. Salbutamol was the first selective β2-receptor agonist to be marketed in 1968. 2. It was first sold by Allen & Hanburys under the brand name Ventolin. 3. The drug was an instant success, and has been used for the treatment of asthma

ever since.Example:1. Neb 0.5%/10mls: 2ml up to 4 times daily (over a period of 3 mins)2. Injection 0.5mg/ml • S/CorIM500mcg4hourly • SlowIV250mcg • IVinfusion,initially5mcg/min • adjustedaccordingtoresponseandHR,usuallyintherange3-20mcg/min3. Metered dose inhaler (MDI) 100mcg/puff: 2 puffs PRN4. Dry powder inhaler (DPI) 200mcg/puff: 1 - 2 puff PRN5. Tab 2 mg • 2-6yrs:1-2mgTDS–QID • 6-12yrs:2mgTDS–QID • >12yrs:2-4mgTDS-QID6. Syrup 2mg/5ml • 2-6yrs:1-2mgTDS–QID • 6-12yrs:2mgTDS–QID

Salbutamol1. As a β2-agonist, salbutamol also finds use in obstetrics.2. Intravenous (IV) salbutamol can be used to relax the uterine smooth muscle to delay

premature labor (5mg/5ml).3. It’s role has largely been replaced by the calcium-channel blocker (nifedipine), which

is more effective, better tolerated and orally administered.4. Diet and body building use: • Salbutamolistakenbysomepeopleasanalternativetoclenbuterolforpurposes

of fat burning and/or as a performance enhancer. 5. Detection of use • Salbutamol may be quantified in blood or plasma to confirm a diagnosis of

poisoning in hospitalised patients or to aid in a forensic investigation. • Urinary salbutamol concentrations are frequently measured in competitive

sports programs, for which a level in excess of 1000µg/L is considered to represent abuse.

• Thewindowofdetectionforurinetestingisontheorderofjust24hours,giventhe relatively short elimination half-life of the drug.

6. Doping • Clinical studies show no compelling evidence that salbutamol and other β2-

agonists can increase performance in healthy athletes. • Inspiteofthis,salbutamolrequired“adeclarationofuseinaccordancewiththe

International Standard for Therapeutic Use Exemptions” under the 2010 WADA prohibited list.

• Thisrequirementwasrelaxedwhenthe2011listwaspublishedtopermittheuse of “salbutamol (maximum 1600 micrograms over 24 hours) and salmeterol when taken by inhalation in accordance with the manufacturers’ recommended therapeutic regimen“.

• Accordingtotwosmallandlimitedstudies,performedoneightand16subjects,respectively, salbutamol increases the performance even for a person without asthma.

73



SLIDE 20

Assessment Of Bronchodilator Therapy

1. General assessment: • Monitoringvitalsigns(RR,PR,breathsounds)

2. Specific : • MonitorPEFR • ABGorSpO2inacutestate • K+andbloodglucose • Ifonlongterm–monitorPFT • Actionplanforasthmapatients • Patienteducation • Correcttechniqueofaerosoldelivery • Cleaningofaerosoldevice

SLIDE 19 Salmeterol

DPI 50mcg/puff : 1 puff BD• Seretideaccuhaler(50/250mcg)/puff• Seretideaccuhaler(50/500mcg)/puff• Weakerthansalbutamolbutmorebeta2selective• Durationofaction:3–12hours• Usuallycombinedwithsteroids

Formeterol• DPI4.5mcg/puff:1-4puffsBD(max:8puffs/day)• Symbicortturbuhaler(160/4.5mcg)/puff• Lastfor12hours

Toxicity• Skeletalmuscletremor• Significantβ1 effects (tachycardia) at high clinical dosage• Arrhythmiasmayoccurwhenusedexcessively• Tolerance,tachyphylaxis(lossofresponsiveness)isanunwantedeffect

Adverse effects1. Common side effects : • Tremor(20%),nervousness(15%in2-6yearsold), insomnia(11%in

6 - 12 years old receiving 4 - 12mg BD, headache (4 - 7%), palpitations and tachycardia

2. Specific side effects: • Dizziness(1-7%),nausea(10%),hypokalemia,lossofbronchoprotection,

hyperglycemia, worsening ventilation perfusion ratio • CFCinducedbronchospasmismanagedbyreplacingHFApropellants



SLIDE 22

Ipratropium bromide1. Quaternary antimuscarinic drug

2. Delivered directly to the airways by pressurized aerosol (MDI)

3. Minimally absorbed (systemic effects are small)

4. In excessive dosage, minor atropine-like toxic effects may occur

5. Does not cause tremor or arrhythmias

6. Need to teach clients how to use properly: • If using ipratropiumbromidewithabeta-agonist (SABA), usebeta-

agonist 5 mins. before ipratropium bromide • If using ipratropium bromide with an inhaled steroid or cromolyn,

use ipratropium bromide 5 mins. before the steroid or cromolyn - bronchioles dilate & drugs more effective

7. Example:

• Neb0.5mg*/2.5mg→ 1 - 2 unit doses (1/1 TDS - QID) • Neb0.0125%(125mcg/ml)→ 100 - 500mcg up to 3X/d

→ adult: up to 4X/d • MDI(20mcg*/50mcg)/puff→ 1 - 2 puff qid (Max: 8 puff/d)

8. Adverse effect

Common • Cough(5.9%)anddrymouth(2.4%-MDI;16%-DPI:garglethemouth) • Occasional(): • Bronchitis (10 - 23%), dizziness (2.4%), headache (2.4%), <1%

(nervousness, irritation, palpitation)

Occasional • Bronchitis (10 - 23%), dizziness (2.4%), headache (2.4%), <1%

(nervousness, irritation, palpitation)

SLIDE 21 Mechanism of Action• Competitively blocks / inhibits muscarinic receptors in the airways

(cholinergic induced bronchoconstriction)

• Effectivebronchodilatorsbutnotaspotentasβ2-agonist

• Preventsbronchoconstrictionmediatedbyvagaldischarge(antagonizingeffects of acetylcholine)

airway relaxation



SLIDE 23 Methylxanthines

1. Purine derivatives

2. Bronchodilation is the most important therapeutic effect

3. CNS stimulation, cardiac stimulation, vasodilation and slight increase in BP (due to release of norepinephrine from adrenergic nerves)

4. Found in plants and provide the stimulant effect of 3 common beverages:

• Caffeine(coffee) • Theophylline(tea) • Theobromine(cocoa)

5. Ineffective by aerosol

6. Must be taken systematically (orally or IV) (treatment for asthma)

Example: THEOPHYLLINE and several analogs: i. Orally active (125mg) ii. Available as salts and base, poorly water soluble

SLOW-RELEASE (SR) THEOPHYLLINE 250mg: i. For control of nocturnal asthma ii. Most important in clinical use

→ AMINOPHYLLINE 25mg/ml: i. a low therapeutic index & range (monitor levels frequently – TDM) ii. Water soluble

Clearance varies1. Highest in young adolescents

2. Higher in smokers

3. Concurrent use (drug-drug interaction) of other drugs that inhibit or induce hepatic enzyme (eliminated by cytochrome P450-drug metabolizing enzyme in the liver):

• Reductions in clearance (half life & effects of theophylline): cimetidine,erythromycin, claritromycin, allopurinol, propanolol, ciprofloxacin, ticlopidine ects

• Enhance in clearance (effects of theophylline): rifampin, carbamazepine,phenytoin, phenobarbital, charcoal-broiled meat & cigarette smoking

a. Theophylline and beta-adrenergic agonist given together - synergistic effect can occur→cardiac dysrhythmias.

b. Due to large interpatient variability in theophylline clearance, routine monitoring of serum theophylline concentrations (TDM) is esssential for safe and effective use.

c. A steady-state range: 5 – 15mcg/ml (most patients). d. Common adverse effects: • GIdistress(itmaypromoteacidreflux,alsoknownasGERD,byrelaxingthe

lower esophageal sphincter muscle) • Tremor • Insomnia

4. Others: • Anorexia,nervousness,dizzines,palpitations,restlessness,flushing

5. Overdosage • Severe nausea and vomiting • Hypotension • Cardiactachyarrhythmias • Convulsion/seizuresC/I: severe cardiac dysrhythmias, hyperthyroidism, peptic ulcer disease (increases gastric secretions)



Handling Of Inhaler DevicesMetered Dose Inhaler (MDI)

SLIDE 24

STEP 1:

Remove the mouthpiece cover.

STEP 2:

Hold the inhaler in an upright position as shown in diagram.

STEP 4:

Exhale slowly and completely through your mouth before holding your breath.

DO NOT exhales into the mouthpiece.

STEP 5:

• Deviceshouldbeheldatanuprightposition.

• Insertintomouthwiththeheadslightlytilted.

• DONOTbitesthemouthpiece.

STEP 3:

Shake the MDI 3 - 5 times in an up -down motion before each puff to mix the contents of the canister.



Handling Of Inhaler DevicesMetered Dose Inhaler (MDI)

STEP 6:

Begin inhaling slowly through the mouth (1) and simultaneously actuate the MDI ONCE (2). Continue inhalation for about 3-5 seconds until the lungs are full (3).

STEP 7:

Hold breath for 4 -10 seconds and leave the inhaler in the mouth while holding breath.

STEP 8:

Remove inhaler (1) from mouth and exhale slowly (2).

STEP 9:

Wait 30 seconds to 1 minute before repeating step 3 - 8 if subsequent doses are required.

STEP 10:

Close cap and keep the inhaler in a dry place.

NOTE: • Patients should be advised to garglewithwater after using certain types ofMDIs e.g. Inhaled

Corticosteroids (ICS).• Ifontwotypesofinhalers(steroid&bronchodilator),itisrecommendedtousethebronchodilator

first and wait for 5 minutes before using the steroid.

MAINTENANCE:• Cleantheplasticmouthpieceonly,notthemetalcanister.• Cleanitwithtapwateratleastonceaweek.

SLIDE 24 cont

2

1

1

2

3



SLIDE 25

SpacerI. BI – tube

STEP 1:

Remove the mouthpiece cover from the metered dose inhaler (MDI).

STEP 2:

Attach the large end of the BI tube to the mouthpiece of the MDI.

STEP 3:

Shake the MDI 5 times in an up -down motion (as shown in diagram) before use.

STEP 4:

• Exhale slowly andcompletely through the mouth before holding the breath.

• DO NOT exhalesinto the BI tube.

STEP 5:

Press the base of the canister (1) and inhale the nebulizer aerosol (2).

STEP 6:

Hold breath for 5-10 seconds.

STEP 7:


STEP 8:

After use, remove the BI Tube and replace the mouthpiece cover on the MDI.

MAINTENANCE:

• WashtheBItubeatleastONCEAMONTHwithtapwaterandairdry.

• DonotwipetheBItubedryafterwashing.



SLIDE 25 cont

II. Chamber With Mask

STEP 1:

Visually check for foreign objects before each use.

STEP 2:

Remove the mouthpiece cover from the MDI.

STEP 3:

Insert the MDI into the adaptor of the chamber.

STEP 4:

While holding the chamber with MDI firmly, shake the MDI for 5 times in an up-down motion (as in diagram).

STEP 5:

Apply mask to face and ensure that there is a good seal.

STEP 6:

• PressMDIONCEatbeginning of normal breath.

• Breathe normallybetween 5 - 10 breaths while holding the mask firmly to your face.

STEP 7:

Slow down inhalation if the WHISTLE sound is heard.

STEP 8:


MAINTENANCE:

• ItisrecommendedtocleanONCEAWEEK.

• CleaningoftheproductvariesbetweenthedifferentvariantsoftheAeroChamber®.Pleasereferto each individual product information



SLIDE 25 cont

III. Chamber With Mouthpiece

STEP 1:

Visually check for foreign objects before each use.

STEP 2:

Remove the cap from the MDI and the mouthpiece cover of the chamber.

STEP 3:

• Insert theMDI intothe adaptor of the mouthpiece (1).

• While holding themouthpiece with

• MDI firmly, shakethe unit for 5 times in an up-down motion as shown in diagram (2).

STEP 4:

Put the mouthpiece in the mouth.

STEP 5:

• Simultaneously pressthe MDI ONCE (1) at the beginning of a slow and deep inhalation (2).

• Holdbreathaslongaspossible, between to 4-10 seconds before breathing out through the nose.

STEP 6:

Slow down inhalation if a WHISTLE sound is heard.

STEP 7:


MAINTENANCE:

• ItisrecommendedtocleanONCEAWEEK.

• CleaningoftheproductvariesbetweenthedifferentvariantsoftheAeroChamber®.Pleaserefertoeach individual product information leaflet.

1

2



SLIDE 25 cont

AcuhalerThe dose counter read 60, indicating the full number of doses.

STEP 4:

• Putthemouthpieceinto the mouth and ensure a good seal.

• Breatheinforcefullyand deeply through the mouth only.

STEP 5:

Remove the Accuhaler® fromthe mouth and hold breath for 10 seconds or as long as possible.

STEP 6:

• Closethedevicebysliding the thumb grip back to its original position until a “CLICK” sound is heard.

• The lever willreturn to its original position and will be reset.

STEP 7:

• Repeat step 1 - 6 if more than one dose is required.

• Closecapandkeepthe inhaler in a dry place.

STEP 1:

• Holdtheoutercasein one hand and put the thumb of the other hand on the thumb grip to opentheSeretide®Accuhaler®.

• Push the thumbgrip as far as it will go until a “CLICK” sound is heard.

STEP 2:

• Hold the devicehorizontally with the mouthpiece towards the patient.

• Slide the lever asfar as it will go as in diagram until another “CLICK” sound is heard to load a dose in the device.

STEP 3:

• HoldtheAccuhaler®away from mouth and breathe out completely.

NOTE:

• PatientsshouldbeadvisedtogarglewithwaterafterusingtheSeretide®Accuhaler®.

• Number5to1appearREDtowarnthatthereareonlyafewdosesleft.

MAINTENANCE:

• WipethemouthpieceoftheSeretide®Accuhaler®withadryclothortissuetocleanit.

• TheAccuhaler®isrecommendedtobecleanedatleastONCEAWEEK.

• Thecontentofthedeviceissusceptibletomoisture.Forthisreasonkeepitinadryplaceawayfrom humidity.



SLIDE 26

STEP 1:

Unscrew and lift off the cover.

STEP 2:

• HoldtheTurbuhaler®uprightwiththegripfacingdownwards.

• Turnthegripasfarasitwillgo(1)andthenturnitback as far as it will go in the opposite direction (2) until a “CLICK” sound is heard.

• PerformthisprocedureTWICE.

STEP 1:

Unscrew and lift off the cover.

STEP 2:

• HoldtheTurbuhaler®uprightwiththegripfacingdownwards.

• DO NOT holds the mouthpiece when turning the grip.

STEP 3:

To load the Turbuhaler®with a dose, turn the gripas far as it will go in one direction as shown in the diagram.

STEP 4:

Then turn it back again as far as it will go in the opposite direction until a “CLICK” sound is heard.

TurbuhalerA. Preparing a new Turbuhaler (Priming)

B. Used Turbuhaler

1

2

83



SLIDE 26 cont

B. Used Turbuhaler cont

STEP 5:

Breathe out away from the mouthpiece.

STEP 6:

• Placethemouthpiecegentlybetweenthelips.

• Ensureatightsealarounditasindiagram.

STEP 7:

Breathe in forcefully and deeply through the mouth only.

STEP 8:

• RemovetheTurbuhaler®fromthemouthbeforebreathing out again.

• DONOTbreathesintothemouthpiece.

STEP 9:

Repeat step 2 - 8 if more than one dose is required.

STEP 10:

Replace the cover and store Turbuhaler® in a dryplace.

NOTE: • PatientsshouldbeadvisedtogarglewithwaterafterusingsteroidcontainingTurbuhalers®.• If on two types of Turbuhalers® (steroid & bronchodilator), it is recommended to use the

bronchodilator first and wait for 5 minutes before using the steroid.• Turbuhaler®has a dose indicator that showshowmanydoses are left in the inhaler. Itmoves

slowly when each time a dose is loaded. When the red colour first appears in dose indicator, it shows that there are only 20 doses left.

MAINTENANCE: • Cleantheoutsideofthemouthpieceonceaweekwithadryclothortissue.• Neverusewateroranyotherfluidwhencleaningthemouthpiece.

2

56

38

47

36

45

2



SLIDE 27

Easyhalera. Preparing the powder inhaler for first use

b. Delivering the medication

STEP 1:

Remove the powder inhaler from the laminated pouch.

STEP 2:

• Insert the powder inhaler into theprotective cover.

• Thedustcaponthemouthpiecepreventsaccidental actuation of the inhaler when inserting it into the protective cover.

STEP 1:

Remove the dust cap.

STEP 2:

• Shakethedevicepriortoeachdose.

• Aftershaking,holdthedeviceintheuprightposition.

STEP 3:

• Press the device onlyONCEbetween thethumb and forefinger until a “CLICK” sound is heard.

• Keep holding the device in the uprightposition.

STEP 4:

Breathe out normally, away from the mouthpiece.

“CLICK”

Protective cover

85

Dust CapDust Cap



SLIDE 27 cont

NOTE:• Patients should be advised to gargle with water after using steroid containing

Easyhalers®.• IfontwotypesofEasyhalers®(steroid&bronchodilator),itisrecommendedtouse

the bronchodilator first and wait for 5 minutes before using the steroid.• Easyhaler®hasadosecounterwhichindicatesthenumberofremainingdoses.The

counter turns after every five actuations. When the counter turns red there are 20 doses left.

MAINTENANCE:• The mouthpiece can be cleaned with a dry cloth or tissue. Never use water or any

other fluid when cleaning the mouthpiece.• Inhalationpowdershouldnotbeexposedtohumidity.Ifthepowderbecomesdamp,

it is not suitable for use and should be disposed of.

STEP 5:

• Place the mouthpiece between lips andclose tightly around the mouthpiece.

• Breathe in forcefully and deeply throughthe mouth only.

STEP 6:

Remove the inhaler from mouth and hold breath for 5 - 10 seconds.

STEP 8:

• Putthedustcapbackonthemouthpiece.

• StoreEasyhaler®inadryplace.

STEP 7:

Repeat step 2 - 6 if more than one dose is required.

2

56

38

47

36

45

2


APPLICATION OF PEAK FLOW METER AND SPIROMETRY IN MANAGEMENT OF ASTHMA


TOPIC 6



SLIDE 2

SLIDE 1

Peak Flow as Diagnostic Tool1. Less accurate than diagnostic instruments

2. Cannot be calibrated or checked to assure their performance

3. No graphical display to evaluate effort, quality

4. Current PEF standards of ± percent allow models of instruments to vary by up to 20 %

Peak Expiratory Flow Rate

Person ‘s maximum speed of expiration, as measured with a peak flow meter

APPLICATION OF PEAK FLOW METER AND SPIROMETRY IN MANAGEMENT OF ASTHMA

Learning Objective

• Spirometryandpeakflowmeterarethemostimportanttoolsinmonitoringthecontrolleveloftheasthmatic.

• Peakflowmeteristhecommoninstrumentthatisuseattheprimarycaresetting.

• Abletousepeakflowmeterandanalyzethereading

• Spirometryreadingscaleismoreaccuratecomparetopeakflowmeterindiagnosingapatientlungcapacity. The pro and cons of the instrument is mentioned at the end of the topic.

TOPIC 6:APPLICATIONOFPEAKFLOWMETERANDSPIROMETRY IN MANAGEMENT OF ASTHMATRAINING MODULE FOR HEALTH CARE PROVIDERS



Diurnal variability of peak expiratory low rate (PEFR) greater than 20% for at least three days in a week for two weeks is typical of asthma

Or improvements in PEF

1. 10 minutes after high dose bronchodilator through a spacer (60 liters change)

2. After six weeks courses of inhaled steroids

3. After 14 days of 30 mg prednisolone

4. Assessment of the response to treatment

When is peak flow useful ?

1. Diagnosis occupational asthma

2. Help in diagnosis when spirometry in not available

3. Evaluate response

4. Early detection of worsening asthma



SLIDE 6

SLIDE 5

SLIDE 7

Do I need spirometry to make the diagnosis of asthma – YES • Historyandphysicalarenotreliablemeansofexcludingotherdiagnoses,

or of characterising the status of lung impairment

• Pulmonaryfunctionreportsdonotreliablycorrelatewithsymptoms,andthe two together are needed for disease classification

• Peakflowsareconsideredtoovariabletobeaccuratefordiagnosis.Theyare more appropriately used for disease monitoring

• Childrenover5areusuallyabletoparticipateNAEPP guideline section 3. 2007

As part of asthma action plan1. Provide to all patients a written AAP based on signs and symptoms and /

or PEF • Written AAP are particularly recommended for patients who have

moderate or severe persistent asthma, a history of severe excerbations or poorly controlled asthma

2. Whether PF monitoring, symptom monitoring (available data show similar benefits for each) or a combo of approaches is use, self monitoring is important to the effective self management of asthma.

Peak Flow Monitoring

Long term daily PF monitoring can be helful to:1. Detect early changes in asthma control that require adjustments in

treatment

2. Evaluate responses to changes in treatment

3. Provide a quantitative of impairment



SLIDE 8

SLIDE 9

Spirometry: Suitable for resource limited facility1. Inexpensive and user friendly, spirometers are now readily available for

office use

2. Much more reliable and relatively simple to incorporate into a routine office visit

3. Modern office spirometers are portable, process numeric results automatically and print out pre and post report

4. Accurate results accurate equipment

What is spirometry• Spirometryisapulmonaryfunctiontestthatmeasuresthevolumeofair

an individual inhales or exhales as a function of time

• Spirometry measures how much and how quickly air can be expelledfollowing a deep breath

• Flowortherateatwhichvolumeischangingasafunctionoftimecanalsobe measured with spirometry

• Apowerfultoolthatcanbeusedtoassess,followandmanagepatientswith asthma

• Ismuchmorereliableandrelativelysimpleto incorporate intoaroutineoffice visit

• Spirometryprovidesanobjectivemeasureofairflowobstruction

• Spirometry isnecessary fordiagnosis,peak flow isused formonitoringcontrol

• Is an effort – dependent manoeuvre that requires understanding,coordination and cooperation by the patient

• Itisallaboutthetechnique

• Recommendation is to obtain a sufficient number of manoeuvers ofadequate quality

• Are they acceptable and reproducible, implying that themaximal efforthas been achieved

SLIDE 10

Importance of spirometry1. Provides objective measure of lung function

2. EstablishesairflowobstructionandREVERSIBILITY!

3. Assists in asthma diagnosis and treatment

4. Assists in determining asthma severity and asthma control



SLIDE 13

Spirometry results• Airflow obstruction is indicated by reduced FEV1 and FEV1 / FVC values

relative to reference or predicted value

• Thepredicteddependontheindividual’sagegender,heightandrace

• The numbers are presented as percentages of the average expectedin someone of the same age, height, sex and race. This is called percent predicted.

SLIDE 12

SLIDE 14

Objective measurement• Abnormalitiesoflungfunctionarecategorisedasobstructiveorrestrictive

defects

• AreducedratioofFEV1 / FVC as compared to the predicted value, indicates obstruction to the flow of air to the lungs

• AreducedFVC with a normal FEV1 / FVC ratio suggest a restrictvie pattern

Interpreting spirometry• NormalvaluesforFEV1 and FVC are expressed in both absolute numbers

and percent predicted of normal

• Values forFVCandFEV1 that are above 80% of predicted are defined as within the normal range

• FEV1 / FVC ration declines as a normal part of ageing

Spirometry components1. Forced Vital Capacity (FVC) - the maximal volume of air forcibly exhaled

from the point of maximal inhalation

2. Forced Expiratory volume in 1 second (FEV1) - the volume of air exhaled during the first second of the FVC

3. FEV1/FVC - ratio of FEV1 to FVC, expressed as a percentage

4. Peak Expiratory Flow Rate (PEFR) is the maximum air flow (rate)during forced exhalation

SLIDE 11



SLIDE 16

• Obstructive lung disease changes the appearance of the flow volumecurve

• Aswithanormalcurvethereisarapidpeakexpiratoryflow,butthecurvedescends more quickly than normal and takes on a concave shape

SLIDE 15 Is airflow obstruction present and is it at least partially reversible?Use spirometry to establish airflow obstruction

• FEV1 < 80 % predicted

• A reduced ration of FEV1 / FVC as compared to the predicted value, indicates obstruction to the flow of air to the lungs

Use spirometry to establish reversibility

• FEV1increases≥12%andatleast200mlafterusingashortactinginhaledBeta 2 – agonist

• A 2 to 3 weeks trial of oral corticosteroid therapymay be required todemnonstrate reversibility

Image 1: Volume time curve Image 2: Flow volume loop



SLIDE 17

SLIDE 18

Reliability of spirometry1. Correct technique, caliberation methods and maintenance of equipmemy

are necessary to achieve consistently accurate test results2. Calibration must be performed daily3. Maximal patient effort in performing the test is required to avoid important

error in diagnosis and management (reproducibility)4. Spirometry is an effort – depedent manoeuvre that requires understanding,

coordination and cooperation by the patient – subject who must be carefully instructed

5. Technicians must be trained and must maintain a high level of proficiency to assure optimal results

6. Spirometry should be performed using equipment and techniques that meet standards developed by the American Thoracic Society

Criteria for acceptibility include7. Lack of artefact induced by coughing, glottic closure or equipment problems

(primarily leak)8. Satisfactory start to the test without hesitation9. Satisfactory exhalation with six seconds of smooth continuous exhalation

or a reasonable duration of exhalation with a plateau10. Poor effort can be detected if the patient does not blow long enough

(6 seconds) or hard enough (classic shape)11. Maximal patient effort in performing the test is required to avoid important

errors in diagnosis and management12. Spirometry is generally valuable in children over age 4, however, some

children cannot conduct the manoeuvre adequately until after age 7

Restrictive Flow Volume Loop

The shape of the flow volume loop is relatively unaffected in restrictive disease, but the overall size of the curve will appear smaller when compared to normals on the same scale.



SLIDE 19

SLIDE 21

As part of asthma action plan (AAP)• ProvidetoallpatientsawrittenAAPbasedonsignsandsymtomsand/or

PEF

– Written AAPs are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations or poorly controlled asthma

• WhetherPFmonitoring,symptomsmonitoring(availabledatashowsimilarbenefits for each), or a combo of approaches is used, self monitoring is important to the effective self management of asthma.

SLIDE 20

SLIDE 22

Spirometry may be done more frequently

Depending on clinical severity, spirometry is also useful

• Asaperiodiccheckontheaccuracyofthepeakflowmeter

• Whenmoreprecisionisdesiredtoevaluateresponsetotherapy

• Whenpeakflowresultsareunreliable

Conclusion• Bothspirometryandpeakflowplayimportantroleinthemanagementof

asthma

• Spirometrywouldbeabletodiagnoseasthmaobjectively

• Objective monitoring can be achieve by using peak flow especially inmoderate to severe asthma

Spirometry recommendations

• Atthetimeofinitialassessment

• Aftertreatmentisinitiatedandsymptomsandpeakflowhavestabilised

• Duringperiodsoflossofasthmacontrol

• Whenacessingaresponsetoachangeinpharmacotherapy

• Atleastevery1to2yearstoassessthemaintenanceofairwayfunction

NAEPP guidelines



HOW TO INTERPRET SPIROMETRY RESULT


TOPIC 7



SLIDE 1

SLIDE 2 ATS GuidelineWithin manoeuvre criteriaI. Individual spirograms are “ acceptable “ if a. They are free from artefacts: •Coughduringthefirstsecondofexhalation •Glottisclosurethatinfluencesthemeasurement •Earlyterminationorcutoff •Effortthatisnotmaximalthroughout •Leak •Obstructedmouthpiece b. They have a good starts •Extrapolatedvolume<5%ofFVCor0.15litreswhicheverisgreater c. They show satisfactory exhalation • Durationof≥6seconds(3secondsforchildren)oraplateau inthe

volume time curve or if the subject cannot or should not continue to exhale

II. Between manoeuvre criteria a. After three acceptable spirograms have been obtained, apply the

following tests: •ThetwotargetsvaluesofFVCmustbewithin0.150Lofeachother •ThetwolargestvaluesofFEV1 must be within 0.150 L of each other b. If both of these criteria are met, the test session may be concluded c. If both of these criteria are not met, continue testing until • Both of the criteria are met with analysis of additional acceptable

spirograms or • Atotalofeighttestshavebeenperformed(optional)or • Thepatient/subjectcannotorshouldnotcontinue d. Save as a minimum, the three satisfactory manoeuvres.

Outline1. ATS guidelines

2. Clinical data review

3. Volume-time curve

4. Flow-volume curve

5. Spirometry

6. Reaching a conclusion

7. Cases

HOW TO INTERPRET SPIROMETRY RESULT

Learning objective

• Peakexpiratory flowrateandspirometryare important inassessing the levelofasthmadiagnosisand management. Therefore the interpretation of the results must be accurate. There are a few of Spirometry graph shown in this topic for discussion

TOPIC 7: HOW TO INTERPRET SPIROMETRY RESULTTRAINING MODULE FOR HEALTH CARE PROVIDERS



SLIDE 4

Components of the curve• FVC:heightofthecurve(Figure2)

• FEV1: volume corresponding to 1 sec (Figure 3)

• FEF25,50,75,25-75:extractedfromcurve’s(Figure4)

Slope

Clinical data review1. Clinical history

2. Patient demography

3. Technician’s comments

Figure 1: Volume time curve

Volume time curve

Figure 2

Figure 4

Figure 3



SLIDE 5

SLIDE 7

Examine the post bronchodilator curve

1. Examine the size, shape and location, compared to pre - bronchodilator

2. If the is improvement, it might indicate response to bronchodilator

SLIDE 6

Examine the components of the curve

• Height (PEF) and slope (FEF25-75): low – suggestive of obstructivedisorder

• Width(FVC):smallerthanpredictedcurve,suggestrestrictive(mainly)orobstructive (less)

• 1stsecondmark(FEV1):estimateFEV1/FVC – low suggest obstructive

Good curve quality

• Goodstart

• Smoothcurve,freefromartefact

• Goodend



SLIDE 8

SLIDE 10

SLIDE 11

Special situations• IsolatedlowMMEFORFEFindicatesairflowlimitationatlowlungvolume

• Isolated significant response to bronchodilator with normal baselinesuggest asthma

Reaching A Conclusion’Obstructive disorder:1. You will need then to differentiate between the two major

2. Obstructive disorders – asthma and emphysema:

• FVcurve:a“dog-leg”appearanceischaracteristicforemphysema. • Spirometry: a significant bronchodilator response is suggestive of

asthma.

3. Remember that other obstructive disorders (such as bronchiectasis, obstructive bronchiolitis, and chronic bronchitis) could be responsible.

SLIDE 9

Examine FEF25,50, 75, 25-75

1. If low may suggest obstruction

2. May also be low in restrictive disorder and upper airway obstruction

Look at the rest of the results

3. PEF may decrease in: • Pooreffort • Obstruction • NMD

4. FET: Appropriate exhalation 6 sec

5. Excessively prolonged suggest mild obstruction

Examine FEV1, FVC and FEV1/FVC ratio

FEV1 FVC FEV1 / FVC

Normal Normal Normal NormalObstructive Reduce Normal Reduce < 0.7 Restrictive Normal or reduce Reduce Normal or increaseMixed Reduce Reduce Reduce

Examine the post bronchodilator value of FEV1, FVC and FEV1/FVCSignificant response: 12% and 200ml in FEV1 or FVC



SLIDE 13

SLIDE 12

The following helps for the distinctionFV curve:

1. A small curve with a steep slope suggests a parenchymal restriction.

2. A small curve with a parallel slope to the unpredicted curve suggests a chest wall restriction other than NMD.

3. A convex curve suggests NMD or poor effort study.

Restrictive disorder.The two major groups of disorder involved are as follows:

1. Parenchymal restriction, like ILD

2. Chest wall restriction (NMD, MSD, diaphragmatic paralysis and morbid obesity)


QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA”


CHAPTER 2



SLIDE 1

SLIDE 2 QAPIndicatorinBahagianPembangunanKesihatanKeluarga1. Maternal & Child Health • Incidencerateofsevereneonataljaundice(NNJ)(Std:100/10000) • Visual defect detection rate among standard one school children (Std:

>5%)

2. Primary Care

a. Disease Base • Appropriate Management of Patient with Asthma (Beating own

standard)

b. System Base •ClientFriendlyClinic(Beatingownstandard)

3. Clinical Support • Filmrejectionrate(<2.5%) • Lab-TotalTurnAroundTime(L-TTAT)(>95%lessthan30minutes) • Proportionofwronglyfilledprescriptiondetectedbeforedispensing(0)

What Is Quality Assurance?

Quality Assurance (QA)• Is a process-centered approach to ensuring that a company or organization is

providing the best possible products or services.

• It is related to quality control, which focuses on the end result, such as testing a sample of items from a batch after production.

• Although these terms are sometimes used interchangeably, quality assurance focuses on enhancing and improving the process that is used to create the end result, rather than focusing on the result itself.

• Among the parts of the process that are considered in QA are planning, design, development, production and service

QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA”

CHAPTER 2: QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA”TRAINING MODULE FOR HEALTH CARE PROVIDERS



SLIDE 3

SLIDE 5

SLIDE 4

QAP Indicator - Appropriate Management of Asthma1. Indicator • %ofAsthmaticcasesthatreceivedappropriatetreatmentofAsthma

(6/6)

2. Purpose of indicator • MonitorappropriatenessofAsthmatreatmentbyPHCpersonnel Resulting quality performance hence reduce number of asthmatic

attack and morbidity

3. Advantages of indicator • StatusofAsthmatreatment • PresentAsthmatreatmentisadequateandeffective • IndicatesareastobestrengthenforAsthmatreatment • EnsureuseofCPGonAsthmatreatment

QAP IndicatorAppropriate Management of Asthma

Quality Assurance Process

1. Involve all health clinics with Medical Officer

2. Start off with: • Developmentofbaseline • Remedialmeasures • Periodiccontinuousevaluation

3. Remedial measures include • TrainingandretrainingofPHCpersonnel • Supplyofappropriateandadequateequipments

4. Evaluation process • Basedonanbenchmarkingapproach,doneannuallysothatcontinuous

improvement based on recommendation can be accomplished.

QAP Indicator - Appropriate Management of Asthma



SLIDE 6

SLIDE 8

Criteria for Appropriate treatment of Asthma1. On recommended drugs i.e inhalers

2. PHC personnel using the app. monitoring tools i.e ACT & Levels of Asthma Control (GINA)

3. Client well informed: • Aboutsymptomofasthmaticattackandhashis/herplanofaction • Whenandwheretoseekmedications

4. Client knows: • Whentouseinhalers • Howtouseinhalercorrectly

SLIDE 7

Definitions

1. Asthma • Conditioncharacterisedbyairway inflammationduetoairwayhyper

responsiveness, presenting with episodic or chronic wheeze and/or cough

2. Asthmatic case • PatientbeingdiagnosedtosufferfromBAbyMO/trainedpersonnel.

The diagnosis should be reviewed & confirmed by FMS / M&HO once before inclusion into the study to ensure correct diagnosis

3. App. treatment of asthma • Accepted if the asthmatic case of the HC received care as being

recommended or following the MOGC for treatment of asthma

QAP Indicator - Appropriate Management of Asthma

Outcome

1. Medical outcome • Improvecompliance • Reduceattacksandcomplications

2. Service Outcome • ImprovequalitymanagementbyMedicalAssistantandDoctor

3. Cost Outcomes • Reduceseveremorbidityanditscosts



SLIDE 9

SLIDE 11

Methodology (Baseline And Annual Evaluation)

Data collection

1. Interview

a. Trained paramedic (preferably from other clinic) b. Using questionnaires c. Time of interview • Anyclinicdayatanytimeoftheday. • Takea fewdays toweeks,dependingonhowsoon theexpected

number of samples is reached. • Periodstobeavoided - Rainy seasons - School holidays - Post-public holidays

2. Patient’s record

Methodology (Baseline And Annual Evaluation)1. Type of study • CrosssectionalanalysisofthemanagementofpatientswithAsthma

2. Sampling frame • Allasthmaticpatientsonfollowup

3. Sample size • 10or30%(not>100)

4. Sampling method • RandomsamplingfromAsthmapatient’sregister

5. Exclusion criteria • Mildasthmatic,Severelyill,Inemergency,Children(<12yrs) • Communicationproblem

SLIDE 10

Materials required for App. treatment of Asthma1. Inhalers

2. Asthma register

3. Nebulizer

4. PFM

5. Oxygen cylinder

6. Inhalers

7. Sx record chart

8. Other medications

9. CPG

10. Patient education material



Methodology (Baseline And Annual Evaluation)I Method of Analysis • CompletedquestionnairecollectedandanalysedbyM&HO • Thetotalscoreofperformanceis6 • TheAnalysiswillbebasedonthepercentageofthetotalmarks

Calculation of heatlh clinic performance

Number of respondents achieved 6/6 Total number of respondents

II Limitations of Indicator • Asthmacontrolishighlydependentonpatient’scompliance

III Performance Analysis a. Clinic level • ScoreDistributionChart - Main tool to show the level of appropriateness - Plotted following the year to show the trend

b. District level •ScoreDistributionChart - Plotted to compare performance among health clinics in the district

for the specified year.

SLIDE 12

X 100 %



SLIDE 15

QAP Indicator Appropriate Management of AsthmaRemedial Measures

Using the evaluation, strengths and weaknesses identified to facilitate drawing up of remedial interventions activities:

• TrainingonMOGC

• Adequatesupplyofinstrumentsanddrugs

SLIDE 14

QAP Indicator Appropriate Management of AsthmaQuality status

The status of quality for clinic/district/state in a specific year is determined by comparing the percentage of respondent who gets 6/6 with the median value of previous year

QAP Indicator Appropriate Management of Asthma

Methodology (Baseline And Annual Evaluation)

Performance Analysis

• Mainmonitoringtoolatthedistrict,stateandnationallevelistheIndicatorChart

- Drawn up by year to compare the present performance with the previous year(s).

• Trendofmedian‘percentageofappropriatemanagementofAsthmainthehealth clinics’ is the main concern.

SLIDE 13



MANAGEMENT OF BRONCHIAL ASTHMA IN HEALTH CLINIC: OUTCOME & REMEDIAL MEASURES CONDUCTED AT HEALTH CLINIC TAMPIN SINCE 2008


CHAPTER 3



SLIDE 1 Background• FMSinTampinHealthClinicinvolvedindevelopmentofnationalasthmaQA

in 2002/2003

• StartedtoimplementinTampinHCin2004

• Allasthmapatientregisteredinasthmaregistrationbook

• 2004:FMSinventinitialclerkingsheetforasthma

• UsingordinaryOPDcard

• Medical officers reminded to manage asthma appropriately from time totime

MANAGEMENT OF BRONCHIAL ASTHMA IN HEALTH CLINIC: OUTCOME & REMEDIAL MEASURES CONDUCTED AT KK TAMPIN SINCE 2008

TOPIC: MANAGEMENT OF BRONCHIAL ASTHMA IN HEALTH CLINIC: OUTCOME & REMEDIAL MEASURES CONDUCTED AT KKTAMPINSINCE2008TRAINING MODULE FOR HEALTH CARE PROVIDERS

DOCTOR’S ROOMIN COMMON POOL

COUNTERCOUNTER

PHARMACYAsma layout.indd 112 11/26/14 3:16 PM


SLIDE 4

SLIDE 5

Problem statementInability to sustain good quality of care for patients with asthma in Tampin Health Clinic

Why?

SLIDE 3 Problem identified

• Goodprogressduringinitialyearsbutlaterdroppedbadly

SLIDE 2 Asthma card documentation : 2003-2008• OrdinaryOPDcard(yellowcard)

• Guidedclerkingsheetforfirsttimeevaluation

• A4sizeasthmadiary

• Registrationbook

Year Percentage with full marks (6/6)

2004 45.2%

2005 60%

2006 70%

2007 63.9%

2008 33.1%

INABILITY TOSUSTAIN

GOOD CARE

PATIENTPATIENTSYSTEMSYSTEM

STAFFSTAFF

INABILITY TOSUSTAIN

GOOD CARE



SLIDE 6

SLIDE 8

Problem: Patient factor• Justwanttocometoclinicduringasthmaticattack:mostofthepatient

come at night

• Forgottentochartorbringtoclinic/lostthegivenasthmadiary

• Wantquickfix:shortactingoralbronchodilatorstillpreferred,notcomplyto steroid MDI

SLIDE 7

SLIDE 9

Problem: System factor• Notstafffriendly

• Difficulttosustainperformance

• Toodependentontrainedstaff

• “Pahat&penukul“

Intervention: Staff• Educationaboutasthma

• RegularsupervisionbyFMS

• Provide tool tomake them remember easily; quick guide at outer innerof patient’s folder, guided clerking sheet in line with requirements for appropriate management of asthma

• Designated staff inNCD service to help themmore focus ( but they docover other sites too: multitask, integrated yet specialized)

• Try to stick to same staff for data entry or to ensure staff trained firstbefore enter data

Problem : Staff factor• Changingstaff/doctor :FMSneedtokeeponreminding,supervising&

auditing

• Noassistant/sharingassistantinmostcommonroom

• Toovarietiesofpatients:staffdifficulttofocus

• Sharingpeakflowmeter:manypatientsnotassess

• Difficulttopracticeaccordingtorecommendation:staffforgotteneasily

• Wanttoclearpatientscrowdfast:contsame….

• Newstaff:Misinterpret/wrongdataentry



SLIDE 10

SLIDE 12

SLIDE 11

Intervention: patient• Appointmentsystem

• Home based cardwith diary, appointment date and general info aboutasthma, asthma action plan

Intervention : System• Appointmentsystem

• Guidedclerkingsheetthatcontain6keyquestionsinasthmaQA

• Specialfolder

• Patient’shomebasedcardwithmonthlydiaryfor1year

• PatientseeninNCDsite:allwillbeseenbyparamedicfirstthenseenbydoctor

• Comorbidity:choiceofcard:followsequenceofdominance(DM,HPT,MCH)– guided clerking sheet

6 important questions1. Client is on the recommended drug

2. Public Health Care personnel is using appropriate monitoring tools,

3. Client is well informed about symptoms of an asthmatic attack,

4. Client is informed when and where to seek medication,

5. Client knows when to use the inhaler, and

6. Clients knows how to use the inhaler correctly.

THEN MO

COUNTERCOUNTER

THEN MO



SLIDE 15

Community Nurse / Staff Nurse / Medical Officer NCD Service• Initialclerking

• Explainingaboutallelementsaboutasthmabasedonpatient’sbooklet

• Assessandexaminepatientbasedonasthmainitialclerkingandchecklistup to inhaler technique*

• Registerinasthmaregistrationbook

• Givingappointmenttopatient* And checking patient has filled up ACT correctly and jot down ACT score

SLIDE 14 Work Process

Duties Responsible staff

Registration

Giving ACT to patient Staff at registration counter

Checking ACT

Initial assessment JM/SN/AMO at NCD service

Full assessment MO

Appointment JM

SLIDE 13 Outcome: district performance

Clinic 2012

Tampin 93.3%

Gemencheh 87.1%

Jelai 96.7%

Air Kuning 86.7%

Gemas 84.4%

District Median 89.6%


IMPROVING QA ASTHMA THROUGH A DISTRICT SPECIFIC APPROACH (DISTRICT OFFICE KUALA LANGAT)




SLIDE 2

SLIDE 1

Literature ReviewCPG Management of Adult Asthma 2002

Determination of severity of asthma based on day & night symptoms, limitation of activities, episodes of reliever, nebuliser use and lung function test finding (Intermittent or Persistent)

Global Initiative of Asthma (GINA) guideline 2008Simplified it as controlled, partly controlled or uncontrolled

MOH QAP Appropriate Management of Asthma 2007- 2009

Further random audit on asthma cards at 3 clinics in February 2009 showed that assessment and follow up care of asthmatic patients were not optimum. Patients either came for exacerbations or just to take inhalers)

IMPROVING QA ASTHMA THROUGH A DISTRICT SPECIFIC APPROACH(DISTRICTOFFICEKUALALANGAT)TRAINING MODULE FOR HEALTH CARE PROVIDERS

Improving QA Asthma through a District Specific Approach

2007 2008 2009

30.0% 33.3% 23%

Characteristic Controlled Partly Controlled Uncontrolled (All of the (Any measure following) present in any week)

Daytime None (twice or More thansymptoms less a week) twice / week

Limitations of None Anyactivities

Nocturnal None Any symptoms/ awakening One in any week

Need for reliever/ None (twice or More than twice/ rescue less a week) week

Lung Function Normal < 80% predicted or(PEF or FEV1) personal best(if known)

Exacerbations None



SLIDE 5Indicator & Standard

SLIDE 4

DefinitionOptimal assessment

Assessment of patients covering all of the following 6 criterias

1. Daytime symptoms

2. Nocturnal Symptoms

3. Limitation of activity

4. Need for reliever/ rescue

5. Use of nebuliser/ A&E visit

6. PEFR (percentage over predicted or personal best)

To determine the patients’ level of asthma control based on Global Initiatives For Asthma Guideline (GINA) 2008

General ObjectiveTo increase the percentage of asthmatics receiving optimal assessment during follow up in Kuala Langat Health Clinics.

Specific Objectives1. To identify contributing factors to the low percentage of patients receiving

optimal assessment during follow up

2. To formulate intervention strategies to increase percentage of patients receiving optimal assessment during follow up

3. To carry out remedial actions towards the objectives efficiently

4. To re-evaluate the effectiveness of remedial actions taken

Indicator Percentage of Asthmatics receiving optimal assessment during follow up in Kuala Langat Health Clinics.

Formula Number of patients receiving optimal assessment x 100

Total number of asthmatic patients seen

Standard ≥80%



SLIDE 8

SLIDE 7

SLIDE 9

SLIDE 6 Verification study showed 1. Only 2.4 % of patients being assessed optimally

2. The assessment tools were lacking

3. Knowledge of staffs were also lacking

Problem identified Remedial Action

Immediate Long Term

1. Poor assessment based on the 6 criteria

Development of assessment checklist to aid process by creating ASTHMA RECORD BOOK replacing the OPD card

Continuous monitoring system

(regular audit of the asthma record book)


Immediate Long Term

3. Inadequate assessment tools in clinics (Peak flow meter, mouth piece & Peak flow normogram)

Phase 1: Provision of assessment tools to all consultation, screening and treatment rooms.

Phase 2: Development on “ASTHMA KIT”

Regular checking of tools based on checklist twice a month.


Immediate Long Term

1. Inadequate educational activities for Health Care Providers

Workshops on “Assessment & Management of Asthmatic Patients” for all health care providers.

Regular assignments for AMO on case studies

Mentor – Mentee activities in respective clinics


Immediate Long Term

2. Unestablished local protocol on Management of Asthmatic patients in the clinic

Development of implementation protocol on Management of Asthmatic patients in the clinic

Audit on the implementation in the clinics and identify problems related to it.

Periodic review of the local protocol.



SLIDE 12

QA Asthma: Any changes?

SLIDE 11

SLIDE 13

SLIDE 10

DSA QA Indicator

The percentage of patients optimally assessed at 4th cycle: 79 %Standard≥80%

Together with the DSA…………Phase II

Improved on inhaler technique of patients

• Improveassessmentflow(whentorefertopharmacist)

• ImprovetheknowledgeandskillsofHCPoninhalertechniquechecking

• Createteachingtool–avideoonpatientdemonstratinginhalertechniqueto improve skills of HCP.

• TheprojectwasextendedtotheallSelangorinearly2012 1. The Asthma book was revised. 2. The PEFR normogram was made into a poster form. 3. Asthma diary was distributed to all districts

ProsesPengendalianPesakitAsthmaDiKlinik

2007 2008 2009 2010 2011 2012

30 33 23 28 47 70.9

Patient come to healt clinic

Patient come to healt clinic

determine the levelof asthma control

Evaluate again the asthma

determine the levelof asthma control

Evaluate again the asthma



ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL ASTHMA AT PENDANG DISTRICT




SLIDE 2

SLIDE 1

Indicator Percentage of controlled asthma

Formula:

Total number of controlled bronchial asthma_______________________________ X 100% Total brochial asthma patient

General ObjectiveIncrease the controlled percentage of bronchial asthma

MAIN OBJECTIVES:1. To determine the level of asthma controll in Pendang District

2. To detect the main factor which caused the level of controlled asthma is low.

3. To plan a framework and implement the plan of action in controling the bronchial asthma level.

4. Research and restudy regarding the plan of action is created for effective detection and evaluation should be rule out.

ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL ASTHMA AT PENDANG STRICT

ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL ASTHMA AT PENDANG DISTRICTTRAINING MODULE FOR HEALTH CARE PROVIDERS



Model Of Good CareSLIDE 4

PROCESS OF CARE

Filling system

Registration

Trace the defaulter Screening and PERF reading measurement

History taking and physical examination

Accurate diagnosis based on Athma CPG

Treatment and

counseling

Not controlled Controlled

Appointment Refer to hospital

Severity

Refer to Physician(Medical Officer / Family

Medicine Specialist

Wheeze with ARI < 3 years

Persistent wheeze

YES

NO

Transient early

wheeze (20%)

N= 1246

Ref: Martinoz FD New England J Med 1995: 332:133.8

Process of care Criteria Standard

1. Registration Full patient profile - Age , gender - Address - Phone number

100%

2. History taking History taking based on the criteria in the clinical practice guideline

100%

3. Managing and effective implementation

Managing criteria based on Bronchial Asthma CPG1. Client use the inhaler 2. Health Officer will do record the PEFR reading and

monitor level of asthma control.3. Client must know the symptom of asthma4. client is aware of where to get the medication. 5. Client know the right technique of inhaler6. Client know how to use and when to use the inhaler 7. Uncontrolled case is monitor by the Medical Assistant

100%Nil

4. Defaulter tracing All defaulter cases should be contact within 2 weeks from the actual appointment date.

100%

5. Health education 1. All health care officer should attend the management of bronchial asthma course once a year.

2. Need to establish standard module for Inhalation technique for each patient - handling of inhaler device a practical guide for pharmacist (MoH)

3. Consultation for new patient is after 3 months

4. Consultation for old patient after a year

100%

100%

75%

70%



SLIDE 5

SLIDE 7

Inclusion criteria- All adult bronchial asthma which registered actively since 6 months ago at

each 3 clinics in Pendang District

Exclusion criteria- Bronchial asthma among pregnant mother

SLIDE 6

SLIDE 6

Technique of data collection1. Questionnaire for health officer and patient (client)

2. Visit card for asthma patient is audited retrospectively to get the data

3. Analysis will be done by Pharmacist using the questionairre and interveiwing the client.

4. Monitoring the inhaler techniquePemerhatian teknik menggunakan MDI.

5. Data will be analyze by the SPSS Vertion 16.

Controlled asthma based on CPG of Management of Bronchial Asthma 20021. No difficulty in breathing, cough or tiredness

2. Able to do normal physical activity

3. Sleep well

4. No need to use reliever MDI

5. % Expected PEFR > 80% are expected

MethodologySampling metod:• AllsampeltakenfromasthmaticpatientwhichvisitedfromMarch2009

(verification study) and March 2001 (improvement study)

• All cases which came in March should use inhaler and pharmacist willmonitor the technique of the inhaler (MDI).

• All asthmatic patient whi came in March should gone through thequestionaire process in evaluating the level of knowledge.

• Allhealthcareofficerwhomanagingthepatientat3clinicsshouldbegivenquestionairre to evaluate their knowledge.



SLIDE 7

SLIDE 8 Data analyzed the factors which lead to uncontrolled bronchial asthma 1. Weak monitoring system

Percentage of controlled bronchial asthma in Pendang District

Analysis of the data found that there were several contributing factors that led to cases of uncontrolled bronchial asthma.

Factor Standard Result

Wrong inhaler technique All patient able to perform a correct technique

41% client performed a right technique

Defaulter tracing All defaulter cases should be call within 2 weeks from the missed appointment date

Not done

Incorrect appointment date

Frequent appointment should be given

no

2. Uneffective management

3. Patient compliancy


Monitoring of PEFR technique is not done at the counter

Should done to all asthmatic patient who come to the clinic PEFR examination should be done at the screening counter

48% of client who have PEFR reading. Screening counter did not do the PEFR monitoring at the 3 clinics in Pendang District.

Lack of knowledge among the health officer in asthma management.

All health care officer should have the knowledge about asthma.

31% - Satisfactory (skor >80%)69% - Not satisfied

Failure to iniate the treatment with inhaler

All asthma patient must started with inhaler (MDI)

82 % using inhaler

CPG as the guideline is not use in managing the patient

All clinic is given the Asthma CPG and target of using it is 100%

42% used the guidelines

No record update Inovation of the asthma management record book which is more systematic and easy to be audit.

No


1. Did not use the MDI 100% 50% followed

2. Knowledge about asthma 100% 56% have the knowledge

127



SLIDE 11 Improvement

1. Weakness in monitoring

2. Uneffective management

Identifed weakness Improvement Duration

69 % of the health care officer does not have enough knowledge about asthma

1. 100% of the health care officer who handling the asthmatic patient should have adequate knowledge. (Score >80%)

2. CME is conduct by the FMS or medical officer. All staff should attend this CME at least once a year.

Since December 2009 until present

Monitoring of the PEFR at screening counter

1. Management of bronchial asthma record book should be establish and PEFR record is a must at each clinic and as the guideline.

2. PEFR should be done at each clinic in Pendang District

Since December 2009 until present

Only 82 % of patient using inhaler

1. All patient need to be start with inhaler for asthma case by the Medical Officer or FMS.

2. Management record book should be establish at 3 clinics in the Pendang District

3. Random audit by FMS should be rule out every 3 months (systematically)

January 2010 until present

Asthma CPG is not used and treatment is not based on the CPG

1. Bronchial asthma CPG should be develope



Wrong technique of using the inhaler (MDI)

1. First consultation for all 2. Demostrate the technique to all

the new patient 3. Corrected by pharmacist4. Demonstrate by the patient5. Evaluation by the health officer6. 3 months and follow by year


Weak detection of defaulter tracing

1. To establish a new appointment book.

2. Defaulter case should be contacted by the attendant using the phone number given or by through the nearest community clinic.




SLIDE 11

SLIDE 13 Survey Results DSA

SLIDE 12 % of controlled bronchial asthma cases at Pendang district before / after improvement

3. Client conformity


1. Did not use the MDI

• Inhaler technoque monitoring should be monitor by the Medical Assistant and pharmacist via the exchange card of MDI and MDI inspection


2. Knowledge about asthma

• Reminder about the appointment date by the Asthma Educator.

January 2010 until now

3. Lack of asthma knowledge

• Individual consultation with Asthma Educator every 3 months.

• FGD (Focal Group Disussion) by pharmacist officer every 1 month in Pendang District

January 2010 until now

Criteria Before innovation

After innovation 2010

After innovation 2011

a. Weak monitoring1. MDI technique2. Defaulter tracing

41%0%

71%64%

79%89%

b. Uneffective handling montoring 1. PEFR recruitment2. Staff knowledge3. Treatment based on CPG

48%31%48%

87%82%87%

95%86%95%

a. Non - compliance1. Patient knowledge 56% 71% 79%



SLIDE 14

SLIDE 15

Bronchial asthma cases in Pendang District

Frequency of attendance to Emergency Department before / after improvement



SLIDE 17

SLIDE 18

Management of Bronchial asma patient at Pendang District by Pharmacist

ABNA

Management of Bronchial asma patient at Pendang DistrictSLIDE 16

131



SLIDE 19

SLIDE 20

Research direction

This research is the first step of DSA team to improve and strengthening the management of asthma all over Malaysia and also pediatric group.

References: 1. Appropriate Management Of Asthma: QAP Primary Health Care by KKM

2002: 10, 23, 24 & 25.

2. Asthma Registry Pendang.

3. CPG For Management Of Asthma KKM 2002.

4. Dr. Shahrul Bariyah Bt Ahmad. National Health And Morbidity Survey 2006 (NHMS III) Negeri Kedah Darul Aman 2008; 4,15.

5. Dr.Kuppuswamy RIyawoo. The Goal Is Total Asthma Control 2004

www.redorbit.com/news/health; 1-3.

6. Dr.Norzila Mohamed Zainudin. Asthma Control Beyond Symptoms. Issue 4, Nov 2003.

7. Emmanouil Rovithis et al. Assessing the knowledge of bronchial asthma among primary health care phyisician in Crete : A Pre and post test following education course. 21 st May 2001.

8. R.Khatojia. Classifying Asthma Severity And Treatment Determinants: National Guidelines Revisited. www.ejournal.afpm.org.my/2008v3n3/asthma-severity, 1-3.

9. Prof Dr.Zainuddin Zin: Medical Tribune Towards Improved Asthma Management In Asia: A Control Driven Approach. www.medical.tribune.com by Glaxo Smith Kline.

10. www.guideline.gov/summary, 1-4.

Conclusion

1. Team work • Management of asthmaneed a teamwork fromall staff–Medical

Officer, Medical Assistant, Pharmacist and Asthma educator. • Teamworkfrommultidiciplinarywillleadtoobviousgoodimpact

2. Innovation

Management record bok for asthma patient would encourage and give spirit to the team in handling the patient with systematic

3. CPD (Continous Process Development) :

This researh would hepl the Pendang district to control the level of asthma effectively.


ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL ASTHMA AT HEALTH CLINIC (PERLIS)




SLIDE 1

SLIDE 2

Introduction

Percentage Asthma controlled 2009 - 2010

ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIAL ASTHMA AT HEALTH CLINIC

ELEVATE THE PERCENTAGE OF CONTROLLED BRONCHIALASTHMAATHEALTHCLINIC(PERLIS)TRAINING MODULE FOR HEALTH CARE PROVIDERS

Bil KlinikKesihatan 2009 2010

1 KK Arau 17.2% 40%

2 KK Beseri 23.3% 3.3%

3 KK Kaki Bukit 40% 0%

4 KK Kampung Gial 23.3% 23.3%

5 KK Kangar 15.7% 25.7%

6 KK Kuala Perlis 13.3% 13.3%

7 KK Kuala Sanglang 20% 16.7%

8 KK Padang Besar 10% 13.3%

9 KK Simpang Empat 80% 3.3%

No Criteria Asthma QAP Perlis 2009

1 Inhaler intake 90.4%

2 Use the PEFR and record system 22.1%

3 Aware of asthma severity 98.9%

4 Aware of what to do during asthma attack

86.4%

5 Know how to use asthma as prohylaxis

37.9%

6 Able to demonstrate the correct inhaler technique

75.4%

Rational

Global Iniatiative For Asthma (GINA), Global Strategy For Asthma Management and prevention 2009 (update)• Management of asthma patient is based on level of control and not the

severity classification.• Main aim of treatment is to achieve the target and maintain the clinical

control which included: a. Asthma control evaluation b. Treatment to achieve the control c. Monitoring to maintain the control level



SLIDE 4Indicator

Target >50% Achievement 17%

SLIDE 5

General Objective

To elevate the monitoring of the asthma patient at Kangar district based on GINA classification

Specific objective

• Toconductaresearchandstudythemagnitudeofprobleminmanagingand monitoring the level of asthma control among patient.

• IdentifythecauseofprobleminmonitoringwithoutusingGINA

• Identifystepofimprovement

• Evaluatethestepsofimprovement

Percentage of control monitoring of asthma at Kangar Health Clinic

Indicator Standard

Number of patient monitor according GINA classification x100%

100%No. of active patient who securing receive

treatment

Model Of Good Care (MOGC)

Asthma Management

Process Criteria Standard

Registration Register in asthma registration book 100%

Monitor the level Evaluation of asthma control based on GINA 100%

Asthma education Deliver the asthma education to patient 100%

Level of control record Level of controlled is recorded in the asthma book

100%

Treatment based on level of controlled

Treatment is based of level control 100%

Appointment date after nebulizer / follow up date

1. After nebulizedWithin 2 weeks after nebulized

2. Follow upBased on GINA classification

3. Follow up treatment by Medical Assistant or Medical Officer every 6 or 12 months.

4. Partly Control/UncontrolledFollow up treatment with Medical Officer every 3 months

100%100%



SLIDE 6

SLIDE 7 Asthma controlled year 2009 till 2012

SLIDE 8

Improvement measure conducted1. Help the stadd on how to measure the level of asthma contril every time

the patient visit the clinic

2. Ensure all patients monitoring for each visit

3. Makesure that medical officer give the effective treatment according to the level of control

4. Increase the quality of the asthmatic patient management in the clinic

5. Elevate the control of asthma among patient

Monitoring record1. Modified the asthma record book and ensure the data regarding the asthma

controlled is documented.

2. Established the home based card with GINA classification

Improved staff knowledge

3. Training course for asthma management

• Emphasizeonhowtomeasurethelevelofasthmacontrolforachvisit

• Treatmentandappointmentbasedonlevelofcontrolled

4. Training on how to evaluate asthma level according to GINA

No Health Clinic 2009 2010 20112012

(kriteria lama)

2012(GINA)

1 KK Arau 17.2% 40% 43% 36.7% 77%

2 KK Beseri 23.3% 3.3% 6.7% 3.3% 16.6%

3 KK Kaki Bukit 40% 0% 12% 13.3% 86.7%

4 Kk Kampung Gial 23.3% 23.3% 26.7% 60% 57%

5 KK Kangar 15.7% 25.7% 16.7% 3.3% 16.7%

6 KK Kuala Perlis 13.3% 13.3% 0 56.7% 76.7%

7 KK Kuala Sanglang 20% 16.7% 46.7% 54.8% 53.3%

8 KK Padang Besar 10% 13.3% 40% 6.7% 90%

9 KK Simpang Empat 80% 3.3% 76% 83.3% 36.7%



SLIDE 9 Global Iniatiative For Asthma (GINA), Global Strategy For Asthma Management

and prevention 2009(update)

Management of atshma composed of 4 components:

1. Component 1: Built partnership between the patient and the doctor

2. Component 2: Idetify the cause

3. Component 3: Evaluate, treat and monitor

4. Component 4: Management of asthma attack



Documents

MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL